July-August 2020

Chart Conundrums: Telemedicine — Health Care’s New Documentation Paradigm
By Selena Chavis
For The Record
Vol. 32 No. 4 P. 8

Experts weigh in on potential risks and best practices.

To say that telemedicine has carved out a critical niche within the COVID-19 pandemic would be an understatement. Given the greenlight for reimbursement by the Centers for Medicare & Medicaid Services (CMS), remote care models, which are advancing at breakneck speed, have proven a game-changer for continuity of care.

The good news is that CMS will now reimburse for the vast majority of virtual visits during the COVID-19 pandemic. Also, HIPAA has relaxed some privacy requirements to promote use of these care models. The test for those rolling out telemedicine frameworks lies in proof of a patient encounter. As with the submission of any claim, getting paid is contingent on one important element: documentation.

Vasilios Nassiopoulos, vice president of platform strategy and innovation with Hayes, cautions that the rapid changes occurring will likely create some confusion. “Whenever there is a change, especially on the fly during busy, busy times, there will be confusion. That is guaranteed,” he says. “So, the blanket statement covering documentation requirements is to make sure providers are documenting everything they do during the patient’s telehealth visit—the objective of the visit, assessment, any virtual examination or evaluation of the patient—but most importantly the thought process of what you’re monitoring, what you’re ruling out, and what’s worth following up on with the patient.”

In short, the rule of thumb is err on the side of too much detail.

Risks and Nuances
As telemedicine bridges the gap between all health care stakeholders, including patients, providers, payers, and other allied health organizations, there are important nuances to consider, says Neil Baum, MD, medical advisor at Vanguard Communications. Most notably, the doctor will not be able to touch or examine the patient in person. However, he suggests that, with some creativity, a physical exam can be done virtually.

“For example, a midlevel provider can go to the home and use a stethoscope to listen to the heart and lungs and give the results to the physician and have the information put into the record,” Baum explains. “There are now apps for doing a urinalysis in the home. Also, there are EKG or devices to record heart rate rhythms that can be electronically sent to the doctor to evaluate.”

The novelty of these care models will mean exposure to risk when it comes to evaluating a patient virtually or by phone consultation, Nassiopoulos says. “The biggest [risk] is that, whenever there is an interaction between a clinician and the patient, there can sometimes be a miscommunication or gray areas that are dependent upon the patient following up on any prescribed measures. From a legal point of view, even though many restrictions have been lifted, those possible gray areas or patient noncompliance must be made clear in the patient’s electronic chart,” he notes. “You want to document with as much detail as possible. Keep notes and keep monitoring the case.”

Without this level of granularity, Nassiopoulos believes providers can open themselves up to liabilities if a patient becomes noncompliant. And because the industry is, in some respects, entering unchartered reimbursement territory, it will be critical that health care organizations monitor their claims closely to quickly identify how payers are responding to documentation practices and opportunities for process improvement.

“Organizations have to make sure that they monitor and trace the status of their telehealth claims—were they paid and at the right rate, or were they denied and why. In addition, was the reason for any denial based on the regulations before CMS’s policy simplification, or was it denied because the claim was not submitted with proper codes and modifiers?” Nassiopoulos says. “Most importantly, monitor any delay in adjudication or communications from the carriers about the status of the claims.”

Best Practice Considerations
Foundationally, Baum says that providers should write everything down while conducting a virtual patient visit as well as use a third person to conference in, record the visit, and input data into the EMR to ensure nothing falls through the cracks. Elements essential to claim approval include the following:

• date and time;
• length of conversation;
• provider recommendations; and
• proper coding.

Amid the surge in activity and strain on resources that has accompanied COVID-19, Nassiopoulos says providers would be wise to increase their bandwidth in key areas within the revenue cycle continuum—specifically the coding and auditing departments.

“You want to make sure that your coders are well trained to identify errors on documentation that was submitted by the clinicians,” he emphasizes, pointing out that the rate of documentation and coding errors is already high. “Now, we have new ICD-10 codes, new testing codes, and new telehealth codes all creating confusion for the clinician who doesn’t have time to be trained, let alone update and adjust the clinical documentation appropriately, because they’re saving lives. The burden should be transferred to coders to make sure every single encounter is coded correctly.”

When considering how best to use existing resources, Nassiopoulos suggests reassigning staff to service areas that are seeing a decrease in activity due to COVID-19. For instance, some elective surgeries have been put on the back burner for the time being, and full- or part-time employees assigned to those areas can be used more strategically.

Reallocating on the back end—for example, people within patient financial services whose day-to-day scope of work has decreased—is another area where resources can be optimized. “Utilize them, because they do have the experience to increase your bandwidth for monitoring for appropriate payments or delays,” Nassiopoulos says. “And be aggressive when trying to resolve delays or denials.”

Finally, providers can take advantage of this challenge to level all the silos that exist within the revenue cycle continuum and between revenue cycle and clinical personnel. “This is the chance for communication to increase about many of the trends that are being noticed, such as reasons for denial. If the errors are coding, then go back to the coders with internal communication training, mitigation of the root cause of the denials, and so forth,” Nassiopoulos explains, pointing out that this effort should be led by the revenue integrity department or a COVID-19 committee comprising key stakeholders on the compliance and financial sides of house. “There should be at least weekly communications between those pillars to make sure that they are not inadvertently building thicker walls on the already existing silos.”

Future Impact
While telemedicine may have faced its fair share of reimbursement hurdles in recent years, Baum says that the tides are sure to change. “The toothpaste is out of the tube. You won’t be able to put it back in the tube,” he says. “This is a form of communication that is attractive to patients, and once the doctor becomes comfortable with the technology, the doctor will become more efficient and more productive.”

Baum believes telemedicine can help alleviate concerns over a physician storage and that patients as well as payers will embrace the new technology. “There’s no going back. It’s not a situation of ‘if’ the doctor will conduct virtual visits, but ‘when’ he or she will start using this technology to enhance the doctor-patient relationship.”

The way telemedicine expands in the coming years will depend largely on how third-party carriers, including CMS, behave when it comes to processing claims, says Nassiopoulos, who points to the amount of additional work it generates in revenue cycle departments and for clinicians. “There’s an attempt at simplification, but it’s also confusing and very liquid because there are changes at the same time,” he notes. “While there’s some relief, there is also new fluidity. So, it all depends on how this [current situation] works.”

— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications, covering everything from corporate and managerial topics to health care and travel.