Telehealth vs. In-Person Documentation - the Same, only Different

While the goal of a telehealth visit is the same as a face-to-face visit, there is additional documentation needed to support billing this type of service. Documentation of telehealth visits is critically important and often misunderstood. This article reviews the importance of documenting information specific to telehealth visits (both audio with video and telephone only) according to best practice guidelines.

The Center for Medicare and Medicaid Services (CMS) has not given explicit written guidelines on all elements needed for telehealth visit documentation, but we can use the practices deemed best historically, found in previous Medicare and OIG audits, as a guide.

Why discuss telehealth documentation?

Telehealth visits have received more attention due to the surge in their adoption as a result of the Covid-19 pandemic. Increased billing corresponds to increased payment and that gets noticed by all payors including CMS, especially when payments are for Medicare beneficiaries. Many agencies, namely the Center for Medicare and Medicaid Services (CMS), the Office of Inspector General (OIG) and others, all have a vested interest in ensuring that payment for these visits is accurate.

Documentation for a typical face-to-face visit

Before discussing documentation for a telehealth visit, let’s review what CMS says are the common elements of a typical office visit. Accepted documentation principles to support billing of an Evaluation and Management (E/M) service include but are not limited to (CMS 1995):

• Clear and concise narrative that describes what occurred during the visit

• Chief complaint

• Relevant history of the patient

• Pertinent clinical examination

• Detailed assessment and plan outlining any diagnostic work up or treatment needed

What we can learn from past agency telehealth audits

Looking at past OIG and Medicare audits gives us insight into what additional elements should be documented for telehealth visits. In April 2018 the OIG released an audit report that outlined errors and gaps in the payment of telehealth services (CMS 2018).

Random audit software was used to pull data, with outlier claims excluded (payments of $1 or less). They looked at 100 telehealth claims for dates of service from January, 2014 to December 31, 2015 where there was no originating site claim. An originating site is the facility where the patient is located during the telehealth visit. This was one way to flag potential erroneous claims because according to statutory geographic limitations, there should have been an originating site claim associated with every distant site provider claim.

The OIG contacted practices, requesting clinic policies and procedures for telehealth services. They also contacted originating sites to verify that the patient had actually received a visit from the indicated location. Their goal was to validate the distant site provider claim (CMS 2018).

With the focus on the statutory issues of originating site errors (e.g., non-rural and unauthorized sites) along with ineligible provider submissions (e.g., providers outside of the United States and non-Critical Access Hospital institutional providers), the OIG estimated $3.7 million was paid in error during the audit period.

Gaps discovered were (CMS 2018):

• No claim edits were available to Medicare Administrative Carriers (MACs) to verify that originating sites and provider sites were actually geographically eligible to receive payment

• MACs could not implement some related claim edits that were available, which resulted in payment of ineligible claims

• Practitioners were unaware of all geographic restrictions prior to submitting these claims

As claim edits failed, the OIG turned to documentation within the medical record for clarity on site issues and modality concerns (audio with video or audio alone). For claims where this information was not documented within the record, the OIG queried providers for the specifics about these two concerns.

It was decided that CMS must implement a post-payment review process. Administrator Seema Verma sent a letter to the OIG in February 2018 saying CMS agreed with all of the OIG findings and implemented post-payment review monitoring for telehealth services (CMS 2018).

Another audit that gives us insight into what government auditors will be looking for is a Comprehensive Error Rate Testing (CERT) audit published by a MAC, Palmetto GBA, in March 2018 (Palmetto GBA 2018). They found two distinct documentation errors with telehealth inpatient/emergency department consultations (G0425-G0427) and offered tips to avoid these errors (although Medicare no longer covers consultations, they do cover these specific telehealth consultation codes). The first error was insufficient documentation to and from the consulting physician. Tips offered by GBA were (Palmetto GBA 2018):

• Medical necessity should be documented and legible

• Sufficient detailed information on what happened is needed to support medical necessity

• Each encounter should be signed and dated by the performing provider

• Documentation of request for the consult and evidence of correspondence back to the referring physician is required within the record.

The second matter involved technical claim billing issues where information was missing on the claim or missing in the chart when referenced on a claim. Tips for this error were to make sure that the referring and/or ordering physician was listed on the claim and had signed off on orders and referrals within the medical record (Palmetto GBA 2018).

Fast forward to now

With the surge in telehealth billing and payment due to the current pandemic, telehealth has once again been put on the OIG Work Plan for 2020 (Department of Health and Human Services 2020). The Work Plan is the official document that notifies providers of what areas the OIG will focus on to identify improper payments. Now that site restrictions and eligible provider flexibilities have temporarily been suspended, the focus will most likely shift to other elements that remain in place for telehealth visits. Potential areas of focus include:

• Was a consent obtained (either verbal or written) for the visit?

• Was the correct category of code chosen (e.g., office codes for audio with video or telephone codes for audio only visits)?

• Was time calculated correctly (billing provider time not including clinical staff time)?

• Was time documented accurately (e.g., did the billing provider really spend 45 mins with each patient while seeing 20 patients a day)?

This is why additional elements of documentation are needed for the sake of clarity to support billing telehealth services that are not needed for face-to-face visits.

Additional documentation points needed for telehealth visits

Historically we know that ambiguity may mean the difference between keeping the money and giving it back. While the aforementioned basic elements should be documented for all types of E/M services, telehealth visits documentation should also include the following:

• The names of all participants in the visit (e.g., billing provider, nurse, patient, spouse, or guardian)

• Date of the visit

• Whether the visit was real-time audio and video or audio only

• Indication that patient consent was obtained (verbal or written)

• Patient location for the visit (e.g., home)

• Provider location for the visit (e.g., clinic, provider home)

• Clarification of the date the patient was last seen or had billable correspondence (especially if provider is using Check-In or Evisit codes) to avoid date overlap with other billable services

• A clear and concise chief complaint or reason for the visit

• A clinically appropriate history

• A clinically appropriate exam

• A complete assessment and plan for the visit (including pertinent chronic conditions and co-morbidities)

• If billing by time or a time-based code – document the length of time the billing provider spent on the day of the visit with a brief summary of how time was spent (staff time is not included)

Major commercial carriers have generally expressed few documentation requirements for telehealth services, even with recent changes in the last few months. Blue Cross Blue Shield describes “accurate documentation” as needed for telehealth services with “start and stop times for timed services” (Blue Cross Blue Shield of Texas 2020). Humana recommends documenting the modality of the visit (audio with video, audio only, or other means) and refers to CMS guidelines for other documentation criteria (Humana 2020). United Healthcare doesn’t discuss documentation requirements, but does refer to CMS for guidance in coding and telehealth issues (United Healthcare 2020). However, Aetna has published that “documentation requirements for telehealth services are the same as in-office visits.” In addition, Aetna suggests the following best practices (Aetna 2020):

• Providers should document start and end time of the telehealth encounter

• A statement acknowledging the visit was a telehealth visit

• The location of the patient and provider

• The names and roles of any other persons participating in the telehealth service

Although CMS has afforded providers and facilities several temporary flexibilities that have less strict requirements, thorough documentation of telehealth visits is still essential. Detailed information for telehealth visit documentation is important and provides the additional clarity needed to support the type of service billed during this time of flexibility and transition.

Renewal of the current public health emergency has been signed, confirming that telehealth in its current form will be with us for the next few months at the very least. This is all the more reason to make sure your documentation will stand up to potential scrutiny.