Wiki Telehealth documentation requirements

Create Wiki
M

medicalauditor

Networker
Messages
47
Location
Saginaw, TX
Best answers
1
I realize that documentation requirements for telehealth may vary by state, but can someone point me to a resource which provides guidelines about how a telehealth service should be documented? I am looking specifically about the chart note clearly stating that the service was completed using a real-time, synchronous audio and video telecommunications system, and also identifying the system used. I am seeing providers simply stating it was a telehealth visit and billing office visit codes (99202-99215) without specifying that it was an audio AND video visit. I found that some visits were in fact telephone visits (audio-only) but were billed as OV & the chart note only said it was telehealth. Telehealth is a broad category of services and it does not tell me the exact mode of communication. As an auditor, I feel I should be able to verify if the visit was audio-video or not, so just stating "telehealth" is not enough, in my opinion. Moreover, if a visit was initiated as a "video" visit but due to technical issues, was primarily completed as a telephone visit, then the provider must bill telephone E/M codes and not OV codes. Due to these requirements, I like to see documentation that states the visit was completed using audio-video technology. However, as expected, I am getting push-back from providers about this not being a requirement, per current regulations. I think its just common sense and also best practice to clearly document that the visit was completed using audio-video, but if I can find specific guidelines or even just best practices for telehealth documentation from a trusted resource, it would help. Thank you!
 
medicalauditor said:
I realize that documentation requirements for telehealth may vary by state, but can someone point me to a resource which provides guidelines about how a telehealth service should be documented? I am looking specifically about the chart note clearly stating that the service was completed using a real-time, synchronous audio and video telecommunications system, and also identifying the system used. I am seeing providers simply stating it was a telehealth visit and billing office visit codes (99202-99215) without specifying that it was an audio AND video visit. I found that some visits were in fact telephone visits (audio-only) but were billed as OV & the chart note only said it was telehealth. Telehealth is a broad category of services and it does not tell me the exact mode of communication. As an auditor, I feel I should be able to verify if the visit was audio-video or not, so just stating "telehealth" is not enough, in my opinion. Moreover, if a visit was initiated as a "video" visit but due to technical issues, was primarily completed as a telephone visit, then the provider must bill telephone E/M codes and not OV codes. Due to these requirements, I like to see documentation that states the visit was completed using audio-video technology. However, as expected, I am getting push-back from providers about this not being a requirement, per current regulations. I think its just common sense and also best practice to clearly document that the visit was completed using audio-video, but if I can find specific guidelines or even just best practices for telehealth documentation from a trusted resource, it would help. Thank you!
Click to expand...
 
Here is the link to the article that was referenced in response to the question. I was not able to open it using the link provided. I read the article, but it does not answer the question if the chart note has to clearly state that an audio and video telecommunications system was used during a telehealth visit. The article clearly explains how to document an audio only call. Hopefully there is an answer to this question. Thank you! https://namas.co/telehealth-fact-sheet-and-e-m-tips-for-2024-revised-02-2024/
 
Hi there, I agree with you and so does the HHS Office of Inspector General. In a recent audit report the OIG identified failure to report the type of visit (in-person, telehealth or telephone) and reporting telephone visits with an office E/M code as errors.

The OIG also identified a failure to document the specific platform the provider used for an A/V visit, which is essential to demonstrating that the visit was HIPAA-compliant.

https://oig.hhs.gov/oas/reports/region1/12100501.asp
 
Hi, and thank you for your response. It was very helpful. After accessing the link you provided, I clicked on and reviewed the complete report. On pages 11 and 12 there is a section titled "Potential Documentation Issues Related to Telehealth" that was very informative. :)
 
jkyles said:
Hi there, I agree with you and so does the HHS Office of Inspector General. In a recent audit report the OIG identified failure to report the type of visit (in-person, telehealth or telephone) and reporting telephone visits with an office E/M code as errors.

The OIG also identified a failure to document the specific platform the provider used for an A/V visit, which is essential to demonstrating that the visit was HIPAA-compliant.

https://oig.hhs.gov/oas/reports/region1/12100501.asp
Click to expand...
Thank you, this is very informative.
 
You must log in or register to reply here.
Top