Ask an Auditor: Telehealth in the Time of COVID - FAQ, Part 1
auditing, medicare, e/m audits, CMS, audit manager, medical auditing software, e/m services, Medicaid, ask an auditor, post-audit results, modifiers, MDM, monitoring, Federal Register, Telemedicine, Telecommunication Technology, Telehealth, Ask An Auditor Anything, COVID-19, health plan
Recently I hosted the webinar, How to Accurately Audit in the Evolving State of Telehealth, where I shared new changes and regulations in light of the COVID-19 pandemic and provided some additional insight into:
- How to Compile Audit Results for Educational Purposes
- What Documentation is Necessary for the Service
- How to Research Payer Websites for Telehealth Information
After I wrapped up the presentation, we opened up the floor to questions. Knowing how rapidly evolving this topic is, in light of the pandemic, there was no hope in answering every question that came in, in such a limited amount of time. So, I told you then, that as time permits, I’d get around to answering your questions in future blog posts. Below, is the first of such posts.
Be sure to subscribe, or come back every week, for more of my answers to your most pressing questions around coding and auditing during the evolving state of telehealth.
(Editor's note: Some questions have been lightly edited for clarity.)
If a patient is being treated with Chemo, would it be safe to say that if the patient is receiving treatment, we bill 99214 or 99215 if we meet the Medical Decision Making (MDM)?
On the Table of Risk, chemo is considered High, due to the fact that this is drug therapy that requires intensive monitoring for toxicity. You'll still have to have the number of diagnoses/treatment options, or the amount of data, as well as the history or exam to meet a 99214 or 99215.
I work for a health plan. As a payer, should we also conduct these audits of our providers?
During the COVID-19 pandemic, CMS and some payers have stated they are relaxing their audits of the telehealth services. However, no one knows what will happen after the pandemic. My recommendation would be to audit providers as per your payer's policies, but to give them some slack since the guidelines change so often. Also, make sure your telehealth guidelines are very clear on your website - and easy to find.
Can you provide a reference to support the need to document patient initiation of the service?
It is in the Federal Register (2020-06990) or in the CMS fact sheet. Consent is required at least annually, and initiation is specifically discussed on these documents in regards to the telephone and e-visits.
Is it CMS and/or payer-required that the media used be documented?
There may be some payers that require it, but as far as most payers and CMS are concerned, it is not a requirement, simply a best practice.
Can you bill an E/M if it is a telephone-only visit?
Not for Medicare. You will need to change it to a telephone visit code.
We submitted our telephone-only visit to Illinois Medicaid with 99348 GT modifier, and 02 POS for a home visit if made in person as per their guideline. And it got rejected. Do you have any information on that?
99348 is not a telehealth code. This is used when the provider actually travels to the patient's home. GT would not be appropriate unless IL Medicaid wants it for some reason.
For telephone visits, if the patient was seen for something other than the phone call, can that phone call visit be billed separately?
Yes, as long as the E/M visit was unrelated to the telephone call, then they can both be billed.
Is it compliant to make an audio and video visit if it was scheduled previously for a patient's chronic conditions?
Yes, audio and video visits can be completed for chronic conditions, so the patient does not have to come into the office.
In your experience, are private payers following the MDM/time requirement for leveling the E/M?
I would say “no,” most of them do not. They still require the three key components, or appropriate time statements.
Could you address the correct coding for hospital outpatient clinics providing E/M telehealth services and the use of an additional facility fee code/charge and/or originating fee charge/code?
The originating fee is supposed to be used when the patient travels to the outpatient clinic, has a telehealth service with a provider somewhere else, and goes home. This is not what is happening in these cases. However, thanks to the "Hospital Without Walls" initiative, the patient's home can now be a "hospital outpatient" which makes it even more confusing. I do not think that billing Q3014 when the patient is really at home is the right thing to do, but we await further clarification. There is a really good AAPC thread in their forum discussing this: https://www.aapc.com/discuss/threads/hospital-telehealth-billing-q3014.173253/
Do you have to get consent from the patient for each visit?
CMS suggests it be done at each visit, but allow it to only be done annually. Best practice is to do it each time.
Since CMS has increased RVUs for 99441 - 99443, will state fee-for-service Medicaid programs do the same? Should we delay submitting claims to allow for this?
I would not delay submitting the claims. If they do increase the RVU, they should reprocess them automatically. Medicaid rarely raises values, and some states don't even pay the telephone codes.
What is your recommendation for scoring E/M services within Healthicity’s Audit Manager, or other audit worksheet tools, accounting for relaxed documentation criteria due to telehealth for COVID-19?
What I have been doing for Medicare patients is to document the chief complaint, then go straight to the MDM section. Once I have audited the MD, I look at the time and give them whichever leads to the higher level of MDM.