• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten the password it can be reset on our sign in section by entering your registered Email Address or Username here. To start viewing messages, select the forum that you want to visit from the selection below..

Wiki Telehealth documentation requirements

Create Wiki
M

medicalauditor

Networker
Messages
69
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