Navigating the telehealth billing rules can be fraught with confusion, even though you’ve been using the pandemic guidelines for nearly three years now. And with Annual Wellness Visits (AWVs) on the telehealth billing list, you must be careful to thoroughly document all of the elements, just as you would when patients are in the office.
How to do this may create some challenges. To ease those issues, consider employing these telehealth billing tips for your AWVs.
Medicare Allows Self-Reported Vitals
Although many of the key elements of an AWV are easy to meet via telehealth, others—like taking the patient’s vitals—are not. However, CMS has said that vitals can be self-reported.
“If the beneficiary is at home and has access to the types of equipment they would need to self-report vital signs (e.g., weight, blood pressure), and if the visit meets all other requirements of the code, this scenario would satisfy the requirements for purposes of billing the AWV code,” the agency noted in a Frequently-Asked Questions document.
If the patient self-reports their vitals, most providers document this by saying something like “Vitals self-reported by patient” in the notes. If the patient is unable to self-report this data, you should note that in the documentation as well, such as saying, “Patient was unable to self-report due to a lack of equipment at home via telehealth during the public health emergency.”
Consider Sending the HRA Ahead of Time
The Health Risk Assessment (HRA) is a key part of the Annual Wellness Visit, and the provider should go through it with the patient during the call. This part is simple to do during the telehealth visit, but what about having the patient complete the HRA?
You have a few options for doing this in the digital age. If the patient is technologically savvy, you can send it to them before the exam via their patient portal, and then go over it together on the call. For many practices, this is the preferred method because it saves time and allows the patient to think about their answers so they don’t have to respond on the spot.
If the patient isn’t tech-savvy, the provider can complete the HRA with the patient over the phone and talk it through while completing it. This does take a bit longer, and if your patient will be completing it this way, you may want to allot more time for the telehealth visit.
Choose Tools for Cognitive Impairment Screening
As part of the AWV, the provider should be detecting any cognitive impairments, which is usually done via a Mini-Cog screening. This can be hard over telehealth, because the patient would have to print it out ahead of time and complete it, which may not be possible due to tech challenges.
Your provider should consider the available screening tools that exist which may serve as alternates to the Mini-Cog, such as the Telephone Interview for Cognitive Status tool. Which tool to use will be up to the provider’s discretion, but you want to make sure your practice is using something to document this element.
Avoid Telehealth for IPPE
Keep in mind that although the AWV is on the telehealth list, the Initial Preventive Physical Exam (IPPE) is not, so the above tips apply exclusively to annual wellness visits.
Want more telehealth billing tips? Coding expert Kim Huey, MJ, CHC, CPC is here to help with her one-hour training session, “Stop 2023 Telehealth Billing & Coding Errors to Keep Cash Flowing.” Kim will cover every element of coding and billing necessary to keep your claims processing smoothly. Register today!
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