The Rise in the Use of Telehealth and Associated Documentation Challenges

There is a common misconception about when telehealth started. Many people, especially patients, believe that telehealth came into existence during the COVID-19 pandemic in 2020. In reality, the concept of telehealth/telemedicine was already thought of by inventors like Hugo Gernsback back in 1925 with his invention called the “Teledactyl.” This device concept would allow providers to see patients through a video screen and “feel at a distance” with specific instruments that a provider can use to manipulate the device in the patient’s room at the same time from afar. Unfortunately, this device concept was never made into reality, but Gernsback did effectively predict and envision the future of telehealth using technology.

The Centers for Medicare & Medicaid Services (CMS) defines telehealth as “the use of electronic information and telecommunications technologies to extend care when you and the patient aren’t in the same place at the same time.” There are many benefits to telehealth, including but not limited to the following: the promotion of continuity of care, management of chronic health conditions, and reduction of travel and healthcare accessibility for vulnerable patients and patients who live in rural populations. Telehealth is not appropriate for all patients, especially those who require a higher level of care that may require an in-person exam or procedure.  

COVID-19 Telehealth Notice

During the COVID-19 pandemic, in March 2020, the Department of Health and Human Services (HHS) issued a temporary notice allowing providers to use popular communication applications like Apple FaceTime, Google Hangouts Video, Zoom, Skype, etc. This notice did specify that public-facing applications like TikTok, Facebook Live, and Twitch are not acceptable and should not be used by healthcare providers. The intent of this notice was to allow providers the ability to use technology that may not be in compliance with the Health Insurance Portability and Accountability Act (HIPAA) rules so that providers can see their patients quickly and safely without being penalized for violating HIPAA rules.

What this temporary notice didn’t address and stress was the importance of documentation. Similar to any professional services rendered in the office or in the hospital, documentation should be performed as accurately and in as timely a manner as possible. Unlike traditional HIPAA compliant applications, these popular communication applications did not have a documentation component where a provider can easily document during their encounter with the patient. Therefore, during the initial days of the COVID-19 pandemic, many providers had limited guidance on how to perform telehealth visits and what was required of them in terms of documentation integrity and billing compliance.

Extending Provisions

Even though the original telehealth notice was intended to be temporary, to allow more patient access during the public health emergency, both CMS and Congress have since taken actions to make some of the provisions permanent or have extended some provisions for further evaluation. For example, CMS utilized its regulatory authority to extend 64 types of services approved for telehealth through December 31, 2023, in order to allow additional time for further evaluation. In addition, CMS has also permanently approved nine service types for telehealth in January 5, 2022. With the data collected during the pandemic, the United States Government Accountability Office (GAO) released a Report to Congressional Addressees addressing Medicare Telehealth ⁴ in September 2022. This report indicated that there is a significant need for oversight surrounding telehealth and that patients need to be educated on risks related to privacy and security. According to this report, “Office visits (including visits to primary care and other practitioners) and psychotherapy were the most common services delivered via telehealth, accounting for about 80 percent of all telehealth services post-waiver from April to December 2020.”

With the increased use of telehealth between providers and patients, CMS quickly took actions in 2020 and 2021 to address the identified program integrity risks related to the new telehealth waivers. These actions included the monitoring of billing claims for suspicious patterns, improper payments, fraud, and abuse. Furthermore, CMS also addressed concerns related to the quality of these telehealth visits. Since CMS’s ability to track these telehealth visits is contingent on reported data, it is vital for providers to be aware of which billing codes should be reported for the many different types of telehealth methods. For example, there are specific billing codes related to office visits delivered via video versus audio-only.

Best Practices for Documentation

To help ensure the documentation in the health record supports telehealth services for all types of payers, below are some best practices related to telehealth documentation that providers can follow:

• Perform documentation at the time of the telehealth visit and complete documentation right after the visit, if possible.
• Be as specific as possible when documenting diagnoses by providing acuity, chronicity, and etiology/manifestation(s). Documentation should be to the highest level of specificity.
• Document the amount of time spent and method used for the telehealth (e.g., phone, secure two-way video, etc.).
• Document the patient’s consent to receiving services via telehealth.
• Document the provider location of where the telehealth visit is being conducted at (e.g., location of clinic, home).
• Document all clinical participants and their roles if they were present during the telehealth visit.

Additional things to consider may include the following:

• Include all other documentation requirements that are required during an in-office face-to-face encounter by utilizing a problem-oriented note format (e.g., SOAP). This will allow a provider to document clearly the patient’s problem in the order in which it occurred. The SOAP note format will give the provider the ability to provide a subjective and objective analysis of the patient’s issue first followed by an assessment and plan.
• Documentation supporting medical necessity.

Telehealth Services Audit

Due to the increased usage of telehealth, in January 2021, the Office of Inspector General (OIG) issued an announcement that it will be conducting a two-phase audit on Medicare Part B telehealth services during the COVID-19 public health emergency. In phase one of the audit, the OIG will focus on assessing whether services like evaluation and management (E&M), end-stage renal disease (ESRD), psychotherapy, and opioid use met Medicare requirements. In phase two, the audit will evaluate whether “Medicare Part B telehealth services related to distant and originating site locations, virtual check-in services, electronic visits, remote patient monitoring, use of telehealth technology, and annual wellness visits” met Medicare requirements.

With the increased use of telehealth and the need for both providers and patients requiring education to ensure compliance and oversight, this presents a great opportunity for both health information management (HIM) and clinical documentation integrity (CDI) professionals. Since HIM and CDI professionals are documentation experts, they can play key roles in educating providers on the various documentation requirements required for coding and reporting.

Incomplete documentation may result in denial of payment for services billed and can also impact patient care across the continuum of care. It is also very important that codes are reported accurately because this is the only way CMS can assess and analyze data related to specific services (like telehealth). This will allow CMS to make “fully informed”  policy-related and/or payment-related decisions for the future.

HIM professionals are skilled to recognize privacy and security issues and can help educate providers on privacy and security risks. In addition, they are excellent resources for both vendors and information technology (IT) team when assessing new tools that may be used for telehealth and/or when an organization is creating policies and procedures related to telehealth processes to ensure compliance with regulatory standards. Healthcare organizations and providers should leverage these experts and implement an internal telehealth audit process to ensure the use of telehealth technology is appropriate, documentation is sufficient and supports the level of care rendered to ensure billing compliance. Last but not least, these internal audits can help identify privacy and security risks.

Maintaining Compliance

This is the time for all healthcare organizations to ensure that they have a strong compliance oversight of telehealth services in both the inpatient and outpatient setting. This oversight will help ensure that the patient’s privacy and security is safeguarded and that the coding and billing practices are compliant.

Anny Pang Yuen (anny.yuen@apconsultingassociates.com) is a principal/independent consultant at AP Consulting Associates LLC