Learn How to Avoid Telehealth Audit Traps

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Learn How to Avoid Telehealth Audit Traps

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OIG Telehealth Audit

It’s now official: your telehealth services are on CMS’ radar. The Office of Inspector General (OIG) just announced that it will start reviewing claims for specific violations.

The last thing you want to do is pay back money for incorrect telehealth reporting. But that’s exactly what could happen if you don’t tighten up your telehealth billing practices. Below are a few mistakes that auditors are looking for and how to avoid these telehealth audit traps.

Abide by Frequency Limits

Virtual visits — brief communication between the patient and provider via any telecommunications technology — are considered a bundled service if you see the patient for a face to face within the previous seven days, or the 24 hours after the virtual visit.

For example, a patient has a virtual check-in that results in telehealth exam. The time for the phone call may not be billed separately — it is bundled with the telehealth visit.

You may bill for telephone visits (99421-99423 for physicians, and 98966-98968 for non-physician providers) only once every seven days. If you have more than one telephone visit with the same patient within a seven-day period, you should track the cumulative time in the patient record, and bill the total one time.

Realize Some Remote Visits Are Not Telehealth

It’s easy to assume that telehealth is a catch-all term that applies to all types of remote patient visits. But when it comes to billing for those services, that’s a mistake. Telehealth means that a provider is furnishing patient care via a live, synchronous stream (synchronous means in real time). E-visits and virtual check-ins are not telehealth.

Why is this distinction important? CMS has opened up telehealth billing to almost all types of clinicians, some of whom are not eligible to bill telehealth services outside of the COVID-19 health emergency. You must make sure that the right providers are billing the right codes, because there are differences in reimbursement.

And if you erroneously bill telehealth codes for services that are not actually telehealth and get paid, you’ll have to return that money as an overpayment. And if a payer sees that you have a habit of making this billing mistake, well, they could multiply the costs over your volume and you’d have owe a hefty amount plus fines.

Conduct Pre-Bill Telehealth Audits

One of the easiest ways to avoid a telehealth billing audit is to conduct your own internal audits. Before you file a claim, review the documentation to make sure all the necessary elements are included. Here are two areas of increased focus:

  • Maximum Daily Time: Make sure you are accurate with your time tracking. Auditors know how much time physicians usually spend on patient care in a day, so if you are regularly exceeding that with telehealth and other virtual visits, auditing software will identify your practice position as an outlier and flag it for a telehealth audit.
  • Supervising Provider: Make sure the provider is authenticating the patient record. This must be the provider who performed or is responsible for the service. For example, when a clinician provides a service “incident-to” a supervising provider, the supervising provider should sign the record.

Follow Payer Rules

It’s a familiar refrain, but all payers are not the same. Check with your individual payer for their exact billing rules, especially at a time when those rules are changing so often. For example, NGS Medicare has removed the seven day/24-hour frequency limitation for telephone services. The only frequency rule that still applies is that providers can’t bill more than one service per day.

For a place of service (POS), you should bill the code that would have applied if the service had been furnished in person, outside of the public health emergency. However, some payers will want you to use the telehealth facility POS 02 instead.

Medicare requires that you add modifier 95 to telehealth service codes. But some commercial payers (and state Medicaid plans) want you to use either -95 or -GT.

For the latest CMS rule, sign up for the online training, “Gain $50 for E-Visits, July 2020 CMS Rule Notice,” by coding and training expert Leonta (Lee) Williams, MBA, RHIA, CCS, CCDS, CPC, CPCO, CEMC, CHONC, CRC. During Lee’s online training, she’ll explain exactly how you can maximize reimbursement for your telehealth services – and how to STOP providing non face-to-face services for free.

Source: OIG Report Audit Workplan: CMS Adds Telehealth Services During the COVID-19 Pandemic


Additional Telehealth Audit Training

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Gain $50 for E-Visits, July 2020 CMS Rule Notice Comply with Tightened Post-COVID-19 HIPAA Telehealth Rules
Earn $110 For Patient Phone Calls, New CMS Rule Applies
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Meet Your Writer

Jen Godreau CPC, CPMA, CPEDC, COPC Content Director

Jennifer Godreau, CPC, CPMA, CPEDC, COPC, has almost 20 years of experience in billing, coding, compliance, and practice management. She develops the content and programs for Healthcare Training Leader, a practice-specific online training company offering step-by-step advice on increasing reimbursement and avoiding compliance violations. Prior to joining Healthcare Training Leader, Jennifer supervised the program delivery for EMRs, practice management systems and compliance and revenue cycle services for more than 6,000 providers. Thousands of software products - encoders, claims management, auditing, and HIPAA compliance, have been created with her teams and helped thousands of practices more easily reduce revenue losses and comply with complex regulations. Her passion for breaking down healthcare rules and requirements in simple steps has provided practical advice, education, and risk reduction strategies to numerous associations, payers and medical specialties especially in primary care, otolaryngology, eye care, and pediatrics. Jennifer’s advocacy resulted in supervision rule revisions, new CPT codes, and CMS compliance contracts. She oversaw the provider auditing and education for one of the major corporate integrity health system settlements. Jennifer has authored and presented on numerous healthcare compliance and payment challenges. Her education guides include the Certified Otolaryngology Coder (CENTC) exam study guide and the AAPC Professional Medical Coding Curriculum. Jennifer has a Bachelor of Arts from Wittenberg University in Springfield, Ohio. She holds certificates in coding, auditing, pediatric coding, and ophthalmology billing and coding, and is AAPC Vice President of the Naples, FL chapter. Please reach out to Jennifer for step-by-step guidance at editorial@hctrainingleader.com