Don’t Let Telehealth Claims Derail Your Accuracy Rates

Don’t Let Telehealth Claims Derail Your Accuracy Rates

Know what to look for when auditing telehealth services rendered during the COVID-19 pandemic.

In October of 2019, I presented a telehealth webinar entitled “Foolproof Tips for Billing Telehealth Services.” I talked quite a bit about the telehealth guidelines that were current at the time and made note that “by next year, telehealth is expected to be a $35 billion industry.”

Well, the joke was on me — I should know better than to say anything is foolproof in this business.

I recently updated the webinar to discuss telehealth auditing specifically, and wanted to share this information with Healthcare Business Monthly readers, as well as discuss a few of the most commonly asked questions.

Different Strokes for Different Folks

One of the challenges of auditing telehealth services is the differences among payers’ policies, especially during the public health emergency (PHE) for COVID-19. Usually, when we get ready to pull charts for audit, we stick to Medicare, Medicaid, and at least one of the big commercial payers such as Blue Cross Blue Shield, United Healthcare, Humana, etc. Then, we audit according to Medicare rules. This won’t work for telehealth claims with dates of service on or after March 1, 2020.

For example, if a physician spends six minutes on the phone with a Medicare patient, the correct code (while waiver 1135 is active) is 99441. One of the Medicaid plans, however, still doesn’t allow the telephone code and requires an evaluation and management (E/M) service to be billed. In addition, they do not accept the Centers for Medicare & Medicaid Services (CMS) allowance of using medical decision making (MDM) or time for new or established office outpatient visits. Not knowing who the payer is, I would allow the 99441, and any claims paid under the Medicaid plan would be wrong.

Let’s break down and review current telehealth auditing processes to avoid such missteps.

Pre-audit Considerations

When you get ready to start your audit, look at your payer mix. Do you see a large percentage of Medicare patients? If so, stick to those for your telehealth audit. If you have a mix that includes Medicaid, research the state’s Medicaid website for telehealth policies. If you see a larger number of commercial payers, try to stick to the two or three payers that have their policies clearly written on their websites. Make a checklist of what each payer wants, or check with your coding and billing department to see if they already have one.

Next, determine how many dates you’ll audit. At AAPC Services, we typically recommend a minimum of 10 dates. If there is an issue, you can usually find it with that sample size. Another option is to use the free software from the Office of Inspector General (OIG) called RAT-STATS. You can plug in your expected accuracy rates and other variables and it can tell you how many and which claims to audit.

When you’re ready to select your sample, choose different levels of E/M services along with a few telephone and e-visits (if you’re doing those). For the E/M services, you’ll know they’re telehealth if they have modifier 95 appended. Depending on your sample size, you could pull a few without the modifier to see if they really were office visits, or if the modifier was forgotten.

Look for This When Auditing Telehealth E/M Services

When auditing E/M office services for Medicare, the information I’ve seen missing from the documentation most often is proof of video. Your provider must document that video was used; otherwise, it will be considered a telephone visit. If I see that there is a valid exam (one that can be performed using video), I might allow the visit but comment that the provider should document that video was used.

In examining the MDM, do not make the mistake of just looking at the documentation of total time. You could shortchange your providers by doing this. Suppose, for example, the provider spends a total time of 10 minutes, but the MDM is moderate. This should be a 99214 based on moderate MDM, not a 99212 based on time. Time is not the deciding factor; use whichever element is greater for code selection.

Remember: This applies to Medicare; not all payers accept using only MDM or time to level E/M visits.

Other things to look for while auditing E/M claims:

  • Patient initiation or consent: CMS states that patient consent for telehealth services may be documented annually. Since this is likely the first time for most patients to receive a telehealth service, you’ll want to make sure the provider has documented consent either in the patient note or somewhere else on file. Best practice is to document it each time.
  • Patient location: Was the patient at home or in a skilled nursing facility? This will affect code selection.
  • Other categories: For E/M categories outside of office outpatient, you’ll still have to audit by the standard elements or the counseling time (greater than 50 percent).
  • Standard auditing: Look for a timely signature, inconsistencies in the note, etc.

Don’t Get Hung Up on Telephone Services

Moving on to telephone services, which may, at first, seem to be a bit easier to audit. The codes are just based on time. But after you read the guidelines for these codes, you realize you’re going to have to look at the patient’s chart to fully audit these.

The telephone codes state that the phone visit cannot be related to an E/M visit during the previous seven days, nor can it lead to the next available appointment for an E/M or other related service. You’re going to have to take an in-depth look at the patient’s chart to see if they have been seen in the previous seven days for a related issue. Look at the phone visit note to see if the provider states the patient must come in for the next available appointment. If so, the phone visit cannot be billed.

Also look at the documentation of total time. If it’s less than five minutes, no code can be billed. What if it’s more than 30 minutes (CPT® code 99443)? A prolonged services code may be appropriate if the payer accepts these codes as telehealth services and the minimum criteria for those services is met.

Patient initiation is another piece that is frequently missing. For phone calls, the patient must initiate the call. Sometimes this can be reasonably assumed, but best practice is to clearly document that the patient initiated the call and consented to being treated over the phone.

The Reality of Evaluating E-visits

E-visits are online messages sent to a provider via a patient portal. Similar to phone calls, you’ll have to review the patient’s chart to see what the cumulative time is over a seven-day period before and after the date of service. The seven-day period begins with the provider’s first personal review of the inquiry.

“The codes include the sum of all communication related to the online encounter, such as phone calls, prescriptions, lab orders, and the like,” according to AAPC Coder.

Review the medical record for all messages related to the same issue within the last seven days. This includes telemedicine visits. For example, if on Monday a Skype visit is performed and billed, then on Wednesday the patient emails the provider for a related issue, that email needs to be included in the Skype visit code.

If the provider documents that this is a quick patient check-in, lasting five to 10 minutes, this is a G2012. Telephone codes 99441-99443 are usually billed for phone calls, but if the provider documents the service as a virtual check-in, and the payer allows G2012, use it instead.

Tie Up Loose Ends

Prepare your report to the provider as usual, and make sure they review it. Some reports require a provider signature, or a read receipt if sent via email. Your report should be clear and concise, and the provider should be given the opportunity to ask questions.

If you’re wondering why you should be auditing your telehealth claims, remember that I thought my first webinar was “foolproof.” I didn’t know what was going to happen, and we still don’t know what could happen next. At some point, CMS or the OIG may consider auditing telehealth services. Complete your audits now and provide education to your providers so they are ready for whatever comes.

Evaluation and Management – CEMC

Lori Cox
Latest posts by Lori Cox (see all)

About Has 2 Posts

Lori A. Cox, MBA, CPC, CPMA, CPC-I, CEMC, CGSC, CHONC, has over 20 years of experience working in the business side of medicine. She began her career in patient accounts and then moved into billing and coding for a multispecialty clinic. Cox was promoted to billing supervisor and then to compliance officer. In 2015, she received her MBA from Quincy University in Quincy, Ill. Cox has traveled the country, educating coders and physicians on complex coding topics such as hematology/oncology and E/M guidelines. She is the member relations officer for the AAPC National Advisory Board, an active member of her AAPC local chapter, and is a regional director for AAPC Services.

Leave a Reply

Your email address will not be published. Required fields are marked *