Outpatient Facility Coding Alert - 2020 Issue 9
Telehealth: Pay Attention to These Details, Prepare for Post-COVID Audits
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Article Overview
This article covers how telehealth billing and documentation are being scrutinized as audit activity resumes after the COVID-19 emergency. It is aimed at medical billers, coders, compliance staff, and providers who document or audit telehealth services. The discussion focuses on broad documentation areas such as encounter modality, timing, and record completeness, along with the compliance context around Medicare-related review activity.
Why This Topic Matters
As audit enforcement resumes, telehealth claims may be examined more closely for documentation support. Understanding the article can help practices assess whether their records are clear enough for review and whether telehealth encounters are documented consistently.
Article Sections
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Medicare Fee-For-Service Medical Review no Longer Suspended
This section describes the post-pandemic audit environment and why telehealth claims may receive renewed attention. It also provides context about the shift in review activity affecting providers and practices.
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Past Audits Suggest Telehealth Errors Are Rampant
This section summarizes prior audit findings and broader concerns about the quality of telehealth documentation. It highlights why claims in this area are considered high-risk for review.
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Confusion Reigns in Medical Practices
This section discusses common documentation confusion seen in telehealth encounters and the importance of recording the communication method used. It focuses on clarity issues that may affect how claims are understood during review.
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Billing Based on Time? Document That Clearly
This section covers time-based documentation considerations for telehealth-related evaluation and management services. It also addresses the need for encounter-specific records and documentation consistency.
What You Will Learn
- Why telehealth claims may face increased post-COVID audit scrutiny
- What types of documentation elements are emphasized in telehealth records
- How encounter modality and time documentation affect telehealth claim support
- Why consistency and specificity in telehealth notes matter for compliance review
Who Should Read This
- Medical coders
- Medical billers
- Compliance staff
- Physicians and other providers
- Practice managers
- Audit and revenue cycle teams
Codes Discussed
Code Ranges Discussed
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