Telehealth Exam Documentation Telehealth Exam Documentation

Finding the Positive in the New Normal- Walking Early into 2020

Scott Kraft, CPMA, CPC Auditing Specialist

This auditing and compliance “Tip of the Week” was originally published by the National Alliance for Medical Auditing Specialists (NAMAS), a division of DoctorsManagement.

 

During the rapid pivot to telehealth services during the COVID-19 pandemic, one of the biggest priorities has been staying on top of the array of CMS and private payer rules to ensure these services were payable. These rules included the clear need in most instances for a video connection with the patient, which types of video were appropriate and how to code services based on time.

I’ve been asked by a number of providers to review their telehealth documentation to ensure compliance with the billing rules for telehealth, and the biggest area that has stood out has been concerns with the documented exams that could result in a payer challenging the integrity of the entire service.

As providers adjusted to documenting telehealth, often exams were being brought forward in the template from face-to-face visits that had already been completed. Parts of the exams were perhaps updated, but not the entire exam. The reason I know this is because some documented aspects of the exam were physically impossible to perform over a video connection.

An ear exam done with a tuning fork can’t be performed via telehealth. The patient’s skin cannot be palpated via telehealth. The tenderness of the abdomen cannot be measured via telehealth. A rectal exam of the prostate gland cannot be done via telehealth.

Despite these impossibilities, I’ve seen all of those elements documented in telehealth exams in the past five weeks. In one instance, the pediatrician asked the patient’s parent to palpate the patient’s skin and share her findings, which were recorded in the chart. While this information may have value, it cannot be credited as part of the provider’s exam.

It’s hard enough to survive a payer audit if the auditor is determined to find the deficiencies in your documentation. Don’t make it easy for them. Scrutinize your exams carefully when reviewing telehealth and ask yourself if the exam item you are reviewing could have possibly been performed during a telehealth visit.

Educate your physicians to focus their exams carefully on things that can logically be examined over telehealth and are pertinent to the patient’s problem(s) that day. Rely on documentation of the total service time, when permitted by the payer, for visits that take a long time but lack the required history and exam elements to support the code.

This Week’s Audit Tip Written By:

Scott Kraft, CPMA, CPC Auditing Specialist

Scott is a Senior Compliance Consultant with NAMAS parent company, DoctorsManagement

What to do next…

  1. Contact us to discuss your audit needs by calling (800) 635-4040 or email info@drsmgmt.com.
  2. Read more: What can you expect from a coding and compliance review?
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