5 Common Mistakes in Documenting a Telemedicine Visit

A recent OIG audit of evaluation and management (E/M) services provided by telemedicine during the pandemic found that providers generally followed the rules for Medicare reimbursement. But they did make some documenting errors

Healthcare providers who use telemedicine often rely on reimbursements to support the platform. And according to a recent audit, they did a pretty good job documenting those virtual encounters during the pandemic.

But while the audit of evaluation and management (E/M) services conducted via telemedicine in 2020 found that most providers met requirements set by the Centers for Medicare & Medicaid Services (CMS) for Medicare reimbursement, some consistent mistakes were noted.

The report, prepared by the Health and Human Services Department’s Office of the Inspector General (OIG), analyzed $10.3 billion in E/M services billed to Medicare between March and November of 2020, of which $1.4 billion, or about 14%, were conducted by telemedicine. The OIG found that providers “generally complied with Medicare requirements” to a point that the agency made no recommendations for changing or improving the coding and reimbursement process.

That being said, the OIG audit identified five common errors in documenting for an E/M visit conducted via telemedicine. They are:

• Documenting how a service was provided. Some providers didn’t document whether the service was done in person or through either an audio-only or audio-visual telemedicine visit.
• Documenting the location of the telemedicine visit. Some providers did not document where the provider or patient were located during the encounter.
• Identifying the telemedicine product used. Some providers documented the use of audio-visual telemedicine for an E/M visit but didn’t identify the platform used (such as Zoom, Microsoft Teams, or a telemedicine vendor). The federal government relaxed both CMS and HIPAA guidelines during the pandemic to enable providers to use more telemedicine platforms, including public-facing products. Now that the pandemic and the public health emergency have passed, the government is again cracking down on telemedicine products that don’t meet rigid privacy and security guidelines and pushing providers to use platforms that are secure.
• Clarifying the telemedicine modality. Some providers documented that they used audio-only telemedicine for the E/M encounter but used an audio-visual telemedicine CPT code, which is different from the audio-only CPT code. The government expanded the use of audio-only telemedicine during the pandemic to expand access to healthcare services but has been pulling back since then to focus on more secure audio-visual telemedicine platforms.
• Documenting problems with the technology. Some providers reported that there were problems with the technology during a telemedicine visit, such as an unreliable internet connection or issues using video. They therefore conducted the visit via audio-only telemedicine but documented the visit as an audio-visual visit.

According to the OIG report, the problems weren’t big enough to indicate the need to take action, but they point to areas of concern that could affect future telemedicine policy. For example, CMS may wish to issue guidance in the future on how providers should deal with technology issues and how they should document the encounter.