The Office of Inspector General is recommending that the Centers for Medicare & Medicaid Service (CMS) more closely review telehealth claims for adherence to requirements and offer education to providers to increase awareness of those requirements.
The year 2020 brought us the novel coronavirus. In response, Centers for Medicare & Medicaid Services (CMS) stepped up to encourage healthcare providers to adopt telemedicine visits to deliver virtual care in the absence of in-person medical visits.
However, telehealth flexibility also increases concerns about potential fraud, waste, and abuse.
A recent pre-COVID-19 audit by the federal Office of Inspector General (OIG) found that majority of telehealth visits were insufficiently documented and unallowable.
Qualified telehealth visits can range from new patients to established patients and from a new problem to an exacerbation of an existing diagnosis. When coders are reviewing charts that are identified as telehealth services, coders need to account for proper documentation of the visit to ensure reimbursement. It’s also important to distinguish between the three types of CMS-approved Medicare Telemedicine Services.
1. The Telehealth visit documentation should be clear and concise. As per the OIG report, a large percentage of telehealth visits were unallowed because the documentation did not include the start/stop times of the medical visit. Many submissions were also denied because the virtual visit site/location of the medical service was missing. Also, if the documentation does not include the encounter type as audio-video, it may not be eligible for Risk Adjustment with Medicare Advantage plans.
2. If the coder identifies in the Telehealth documentation that there was a transfer of care or another face-to-face service (e.g., a surgery, a scheduled office E/M, or a hospital visit occurrence) with a specific timeline identified by the covered health plan policies, this documentation should follow the carrier’s policies and procedures in order for this to be captured for Risk Adjustment.
3. If the documentation indicates a new diagnosis for the patient and requires additional “work up” to confirm the diagnosis yet there is no patient chart information to support the additional work to confirm the diagnosis, then the suspected or working diagnosis code should not be captured as a definitive diagnosis. An example of this is a ‘new-onset’ of COPD. To date, providers cannot listen adequately to the lungs via telemedicine, and, thus, the patient needs an in-person diagnostic exam to confirm the new diagnosis of COPD. The documentation should be present to substantiate the diagnosis made during the visit. If the patient’s chart lacks these elements, then the code SHOULD NOT be captured.
Moreover, new Evaluation and Management Services (E/M) coding guidelines will come out in 2021, putting additional requirements on telehealth visits. In the meantime, you want to ensure that the telehealth visit includes both video and interactive audio detail and documentation. Audio only telehealth communications may not withstand a RADV audit. Check with health plan policies to ensure telehealth visit guideline compliance and that a visit type is valid.
With increased flexibility in telehealth visits comes increased opportunity for fraud, waste and abuse (FWA). It is inevitable that documentation audits are coming as CMS reverse engineers risk controls to mitigate FWA with the recent rapid expansion of telemedicine. But there is good news. There are ways to prevent adverse outcomes. It’s in the documentation.