ED Coding and Reimbursement Alert

EDs may face audits in the very near future.

Your ED has been working under the revised telehealth regulations for several months now, but if you aren’t focusing on the details of your documentation, you may be in for issues down the road.

That’s because CMS announced in July that it planned to resume most Medicare fee-for-service medical reviews by August 3, and although many of those audits will focus on targets that were identified before the COVID-19 emergency began, providers should also be ready for reviews of their telehealth claims as well.

Such was the message from Frank Cohen, director of analytics and business intelligence with Doctors Management, during the firm’s July 16 webinar “Audit Analytics: Post-Pandemic Preparation.” Practices that aren’t prepared for these reviews could face having to refund money they’ve collected, and during a time when providers are already stretched thin financially, he said.

“It’s not just that the pandemic has been a financial disaster for a lot of healthcare organizations, but it’s changing the way the government is going to approach auditing to some degree,” he added. “CMS has said whether or not the public health emergency (PHE) continues into the future, they don’t plan to continue suspending these audits beyond August,” he said.

Past Audits Suggest Telehealth Errors Are Rampant

Although telehealth was in play prior to the pandemic, you could measure the US’ volume of telemedicine services in the tens of thousands at that point, Cohen said. “But since the COVID pandemic, you can now measure them in the tens of millions. By 2026, they’re predicting it will be a $95 billion industry for telehealth.” Therefore, he says, government entities will investigate whether claims for these significant expenditures are being reported and documented properly. However, past audits indicate that errors are common among these claims.

“In a past audit, when the OIG looked at an audit of 100 claims in a sample of all telehealth services, 69 percent met requirements, so that means 31 percent of all telehealth services did not meet requirements,” Cohen said. “If we apply that to a $30 billion market for the government, that means close to $10 billion faces the potential to be recouped. There was a study done in South Carolina in 2016 or 2017 where they found 96 percent of telehealth services were improperly documented.”

Confusion Reigns in Medical Practices

Physicians appear to be quite confused about the difference between audio-only visits and those visits that include both audio and video, says Scott Kraft, CPC, CPMA, senior compliance consultant with Doctors Management. “Most relaxed rules have given you a much wider berth for video communication than what telehealth previously had,” he said. For example, there are things like FaceTime that haven’t been cleared security-wise that are fine during the length of the PHE. However, the burden of documentation lands on the provider to state whether they performed an audio visit or if it included both audio and video.

“I’ve already seen dozens of telehealth encounters in the limited audit work I’ve done in this area where I have no idea based on the documentation if it was audio or video,” he said. However, in the descriptions for the E/M codes that are typically used for telehealth, the face-to-face requirement still applies, and thus the visit has to be done by video.

When audio is used without video, the right codes to report are 99441-99443 (Telephone evaluation and management service…), Kraft noted. “But the burden falls on the provider to make sure it’s clear in the documentation whether the visit is taking place from an audio versus video perspective.”

Practices should always include a statement in the note that makes clear that the visit took place via audio and video communication when applicable, “and I encourage people to document whether it’s via FaceTime or some other service, but it should be clear how the visit was done to ensure that when reviewed, it’s clear that it was a telehealth service and not a telephone service.”

Ensure That Documentation Reflects Reality

Although there are some things that providers can see via audio-video telehealth communication services, others may be harder to evaluate on video, and you should keep those in mind when documenting, Kraft said.

For instance, a fundoscopic exam is unlikely to be performed via telemedicine. However, it has become common for patients to use their digital watches to count their pulse or for the doctor and patient to count the respiratory rate during an interactive process.