Avoid Telehealth Documentation Pitfalls, Part 3 of 5 Part Series

The year 2020 brought us the novel coronavirus.  In response, our friends at the  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 (FWA) and there will undoubtedly be some downstream reverse engineering by CMS to mitigate these inherent risks. Meanwhile, is your organization ready to avoid or pass harmlessly through potential telehealth claims documentation audits?  

A recent pre-COVID-19 audit by the federal Office of Inspector General (OIG) found that 96% of Medicaid telehealth visits in South Carolina were insufficiently documented and unallowable. (1) Whoa!  South Carolina’s alleged noncompliance came down to a lack of training in their documentation practices and an absence of consistent telehealth monitoring controls.  Is this a harbinger of what will happen to telehealth risk-adjusted claims? We think not, as long as organizations provide the necessary education and training on proper documentation.  

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.  As the table below shows, CMS defines Medicare Telehealth Visits as distinguished from Virtual Check-ins and E-visits.  Telehealth Visits are the only service designated to accommodate new patients as well as established patients.  And such a visit is much more involved than an email communication between a provider and a patient through a patient portal, often referred to as an “e-visit.”

Type of Service What is the Service? HCPCS Code Patient Relationship with Provider
Medicare Telehealth Visits Medicare Telehealth Visits Common telehealth services include:
·       99201-99215 (office or other outpatient visits)
·       G0425 – G0427 (telehealth consultations, emergency department or initial inpatient)
·       G0406-G0408 (Follow-up inpatient telehealth consultations furnished to beneficiaries in hospitals or SNFs)
For a complete list:
https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes
For new* or established patients
*To the extent the 1135 waiver requires an established relationship, HHS will not conduct audits to ensure that such a prior relationship existed for claims submitted during this public health emergency.
Virtual Check-In A brief (5-10 minute) check in with your practitioner via telephone or other telecommunications device to decide whether an office visit or other service is needed.  A remote evaluation of recorded video and/or images submitted by an established patient. ·       HCPCS code G2012
·       HCPCS code G2010
For established patients
E-Visits A communication between a patient and their provider through an online patient portal. ·       99421
·       99422
·       99423
·       G2061
·       G2062
·       G2063
For established patients

According to a Pew Research study in 2017, 80 percent of seniors had cell phones but only half had smartphones. Less than a third of seniors owned a tablet or e-reader.  While these rates today likely have increased some, there is uncertainty around how seniors feel confident in using a cell phone or tablet’s capabilities.  Moreover, for risk-adjusted health plan members, caring for patients using audio-only telehealth presents a big problem for reimbursement. Hierarchical condition category (HCC) coding cannot be completed from an audio-only visit.  

In this article, we will identify HCC risk adjustment coding documentation best practices taken from many customer documentation audits, Natural Language Processing (NLP) findings, and customer consultations.  

The coders should watch the following when reviewing the telehealth documentation for Risk Adjustment:

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).

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.

As illustrated above, telehealth documentation include pitfalls or discrepancies that can be flagged for an audit. To further illustrate this, below is an example comparing good versus inadequate telehealth visit documentation to qualify for an HCC billable claim.

As illustrated above, telehealth documentation include pitfalls or discrepancies that can be flagged for an audit. To further illustrate this, below is an example comparing good versus inadequate telehealth visit documentation to qualify for an HCC billable claim.

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Here is an example of a telehealth encounter: the patient complains of calf pain to the physician during an audio-video telehealth visit. The provider interviews the patient on how the calf pain feels and any associated symptoms. The patient also told the physician that he underwent a surgical procedure just recently. Based on the patient’s reported brief history, signs and symptoms, the provider documents the work-up for Deep Vein Thrombosis (DVT) in the assessment and plan sections of the note. The provider instructs the patient that he/she will order a doppler study and labs and set up a follow-up telemedicine visit once results are received.n the note below, the patient complains of calf pain to the physician during an audio-video telehealth visit. The provider interviews the patient on how the calf pain feels and any associated symptoms. The patient also told the physician that he underwent a surgical procedure just recently. Based on the patient’s reported brief history, signs and symptoms, the provider documents the work-up for Deep Vein Thrombosis (DVT) in the assessment and plan sections of the note. The provider instructs the patient that he/she will order a doppler study and labs and set up a follow-up telemedicine visit once results are received.

Inadequate HCC Documentation Example

Chief Complaint: Calf Pain
HPI: (Audio-Visual telehealth visit) Mr. John is here to follow-up on his HTN
ROS: Patient reports of moderate to severe pain 8/10 in his left calf, no injury reported.  No other signs/symptoms.
Physical Exam Findings: Deferred (AV telehealth visit)
Vitals: Deferred (AV telehealth visit)
Assessment/Plan: 1 – DVT, left leg: Ordered labs, Duplex u/s left calf ordered.

2 -HTN: Stable, please continue HCTZ and Lisinopril as directed.

Documentation Inadequacy: In this example, the DVT was diagnosed rather than suspected, since the provider has also described the investigative work-up as pending. Submitting the diagnosis of DVT (HCC code) on this telehealth visit claim will not be correct as the final diagnosis is pending until the diagnostic work-up is completed.

Good HCC Documentation  Example:

Chief Complaint: Calf Pain
HPI: (Audio-Visual AV telehealth visit) Mr. John is here to follow-up on his HTN, and also complains of pain in the left calf since last evening.
ROS: Patient reports of moderate to severe pain 8/10 in his left calf, abrupt onset 1 day ago. No injury reported. The patient reports an orthopedic procedure in the same left leg 4 days ago. Redness and swelling have increased overnight in the left calf area. No chest pain at this time. The patient is having difficulty walking, and cannot bend the left leg at all. The right leg is reported normal usual by the patient. 
Physical Exam Findings: Deferred (AV telehealth visit) Redness around the left calf area noted visually via videocam. Left leg movement causes pain.
Vitals: Deferred (AV telehealth visit)
Assessment/Plan: 1. Calf Pain, left leg: Further investigation is pending- ordered labs, Duplex u/s left calf ordered. Suspecting DVT, left leg. Risk factors noted: recent surgery. Will follow-up after results come back.

2. HTN: Stable, please continue HCTZ and Lisinopril as directed.

Documentation Example for Suspected Condition: The physician makes the diagnosis of ‘Calf pain, left leg’ in the initial telehealth visit note, and also noted that he/she suspects DVT as the reason for calf pain. Upon receiving the results of the doppler study exam, it is confirmed that the patient does have a DVT (Deep Vein Thrombosis).  The provider makes a follow-up with the patient and delivers the final diagnosis of DVT (Deep Vein Thrombosis).  He/she prescribes the patient the appropriate medication for the treatment and reviews the next steps with the patient.  Now the HCC claim for DVT can be submitted with confidence.

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With telehealth expected to top over 1,000,000,000 in 2020 (3), NLP and machine learning technology becomes essential to driving efficiency and accuracy in value-based reimbursement and particularly for HCC claims.  Uncovering buried HCC codes in the mountain of pending telehealth documentation will quickly become a significant task for payers and providers. NLP technology points the coder in the right direction by picking up the documented diagnosis and directing the coder to the next steps of the review process to significantly improve efficiency. Utilizing this technology to find telemedicine documentation gaps helps mitigate the risk of poor audit findings while streamlining workflows to meet the burgeoning demands of telemedicine documentation. 

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.

Disclaimer: Examples in this publication are merely suggestions and cannot prevent an audit. Additionally, telehealth documentation guidelines are changing regularly, please follow CMS for up to date information. (4)

Subscribe to the SHIFT blog to be notified when the next telehealth series article is posted. The next topic in the series is the Telehealth Coding HCC Guidelines. See the prior Telehealth blog post titled, “Telemedicine, Healthcare’s New Differentiator.”

To learn more about Talix’s Risk Adjustment solutions visit www.talix.com.

(1) https://oig.hhs.gov/oas/reports/region4/41800122.asp

(2) CMS Applicability of diagnoses from telehealth services for risk adjustment notification April 10, 2020 https://www.cms.gov/files/document/applicability-diagnoses-telehealth-services-risk-adjustment-4102020.pdf

(3) https://www.beckershospitalreview.com/telehealth/led-by-covid-19-surge-virtual-visits-will-surpass-1b-in-2020-report.html

(4) CMS General Telemedicine Toolkit – https://www.cms.gov/files/document/general-telemedicine-toolkit.pdf

(5)  Medicare Telemedicine Health Care Provider Fact Sheet.-  https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet