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6/30/2020
1
Clearing the Fog - COVID-19 Telemedicine Clinical Documentation Requirements
AllianceChicago - Tuesday, June 30, 2020
Disclosure
As with most topics related to COVID-19, changes are being made rapidly. Please note that this information is current as of
the date of this presentation.
6/30/2020
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Your Presenter
Marla Dumm CPC, CCS-P, CRCManaging Consultant
› Telehealth and virtual communication documentation guidelines• Medical• Behavioral Health• Dental
› ICD-10-CM clinical documentation tips› Q&A
Agenda
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Reminder – Three Virtual Service Lines • A substitute for an in-person E/M or other visit • Synchronous two-way real-time interactive audiovisual communication
or asynchronous store & forward communication• Audio-only E/M or other services will be allowed
Audiovisual (or Phone Only) Telemedicine
(Mapped to G2025)
• Brief five- to 10-minute phone call, initiated by patient, “triage” to determine next steps
• Should not be related to an E/M service rendered in the prior seven days, or result in a scheduled face-to-face appointment within the next 24 hours
E-Checks
(Mapped to G0071)
• At least five minutes of time spent over a seven-day time period
Digital or Portal E-Visit
(Mapped to G0071)
REMINDER: G0071 MAY NOT BE BILLED MORE THAN ONCE EVERY 7 DAYS
General Telehealth
Documentation Criteria
This Photo by Unknown Author is licensed under CC BY-NC-ND
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General Medical Record Criteria› “As telemedicine and telehealth become the new and timely
methods of delivery quality and cost-efficient healthcare with “real time” assessments for patient care when patients are not physical present, health information professionals need to ensure that appropriate documentation is reflected in the record and adherence to all regulatory requirements are met.”
› “Telemedicine records should be kept in the same manner as other health records. The specific documentation needs vary depending upon the level of telemedicine interaction. The organization using telemedicine information to make a decision on the patient’s treatment must comply with all standards, including the need for assessment, informed consent, documentation of event (regardless of the media), and authentication of record entries.”
Source: AHIMA, Telemedicine Tool Kit, Documentation Requirement, Page 23
› “Telehealth services should be documented the same way you would document face-to-face services. You should also add a statement to the effect that the service was provided non-face-to-face, and document the patient’s location, the provider’s location, and the names and roles of anyone participating in the encounter.”
• Source: American Academy of Professional Coders (AAPC), Telehealth Frequently Asked Questions
Another Confirmatory Statement -
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Electronic Medical Record
(EMR) Telehealth
Documentation Guidelines
Documentation must be maintained by both
distant site & originating site (if a health care entity)
Should be in a format compatible with your practice management
(PM) or electronic medical record (EMR)
system
Include verbal consent & acknowledgment•Patient should be notified that third-party applications may introduce privacy risks. Telehealth applications should have encryption & privacy modes
Completion turnaround should be
timely/48 hours
Source: AHIMA, Telemedicine Tool Kit, Documentation Requirement, Page 23
EMR Telehealth Documentation
Guidelines
Assessment of the need for
telemedicine or virtual services
through an initial intake process
Once need is confirmed,
scheduling of telemedicine or
in person appointment
Documentation of encounter content and
orders
Document action steps
and follow-up
Source: AHIMA, Telemedicine Tool Kit, Documentation Requirement, Page 23
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EMR TelehealthDocumentation
Criteria
Rendering provider should document under the same criteria as required for a face-to-face visit
Location of patient (originating site) & rendering provider (distant site)
Names, credentials & roles of any ancillary staff involved in case
Orders
Medical necessity for telehealth or virtual services
Must indicate the type of service (audiovisual telehealth, audio only, E-check or digital/portal E-visit)
Source: AHIMA, Telemedicine Tool Kit, Documentation Requirement, Page 23
EMR TelehealthDocumentation
Criteria
Patient name, ID number (MRN, account #), date of birth, date of service
Referring/ordering physician or non-physician practitioner
Rendering physician or non-physician practitioner
Orders for telemedicine or virtual visit
Document that the visit occurred during the PHE, date and time of visit (can be date/time stamped)
Consent
Source: AHIMA, Telemedicine Tool Kit, Documentation Requirement, Page 23
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EMR TelehealthDocumentation
Criteria
Content and key elements of evaluation or service rendered:History
Review of pertinent notes/consultativePhysical exam to the extent possible (i.e., subjective). Document patient assistance (i.e., reporting of vistal signs, description of pain, video-assisted assessment of anatomical site or injury)
Final impression, diagnosis
Treatment plan and provider signature
Source: AHIMA, Telemedicine Tool Kit, Documentation Requirement, Page 23
› The Interim Final Rule states that providers may assign their audiovisual E/M level of service based on one of the following elements:
1) Time
› Defined = all of the provider time associated with the visit on the day of the encounter› Use the current (2020) E/M times listed in the pertinent code description› Nursing time is not included in start/stop time
• 2) Medical decision making
› Complexity of care using the CMS 1995 or 1997 E/M Documentation Guidelines
› CMS still requires history/physical examination (subjective) to be documented, but removed the requirement to use history and physical examination as required elements for choosing the level of service during the PHE
CMS Waiver – Leveling of Medical E/M Services
Source: Interim Final Rule CMS-5531-IFC, Section Z
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› A patient consent is required for audiovisual, phone-only, e-checks & digital/portal visits
› CMS & state Medicaid indicate consent can be obtained when the service is furnished instead of prior to the service being furnished during the emergency period, but must be obtained prior to billing
› Consent (verbal or written) may be obtained by ancillary staff under the general supervision of the FQHC provider
Consents
Source: CMS Interim Final Rule, Section L(1)(b)
State of Illinois –Documentation Reminders
This Photo by Unknown Author is licensed under CC BY-ND
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State Medicaid –Telehealth
Encounter Details
State Medicaid, in general, mirrors the documentation
expectations outlined by CMS and the healthcare industry
Interactive communication must “at a minimum” allow the rendering provider to examine the patient “sufficiently to allow for proper diagnosis”
Interactive communication must “at a minimum” allow the rendering provider to examine the patient “sufficiently to allow for proper diagnosis”
System must be able to transmit “clearly audible heart tones and lung sounds…clear video images of the patient and any diagnostic tools” such as imaging
System must be able to transmit “clearly audible heart tones and lung sounds…clear video images of the patient and any diagnostic tools” such as imaging
Name and license number of distant site providerName and license number of distant site provider
Source: State of Illinois Administrative Code, Chapter 1(d)(140)(140.403)
State Medicaid –
Additional Telehealth Encounter
Details
“Beginning and ending times of the telehealth service”“Beginning and ending times of the telehealth service”
Medical necessity for telehealth or virtual communication serviceMedical necessity for telehealth or virtual communication service
Key components – CPT E/M components (history, exam, MDM) Key components – CPT E/M components (history, exam, MDM)
Source: State of Illinois Administrative Code, Chapter 1(d)(140)(140.403)
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Tele-Psychiatry
This Photo by Unknown Author is licensed under CC BY-SA
Tele-Psychiatry or Behavioral
HealthDocumentation
Criteria
Rendering provider should document under the same criteria as a face-to-face service
Location of patient (originating site) & rendering provider (distant site)
Names & roles of any ancillary staff involved in case
Orders
Medical necessity for telehealth or virtual services
Must indicate the type of service (audiovisual telehealth, audio only, E-check or digital/portal E-visit)
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Tele-Psychiatry or Behavioral
HealthDocumentation
Criteria
Individual therapy – start/stop time of session, progress toward objectives, participation in session, treatment plan/action plan, etc.
Initial Psychiatric Assessment or Intake
Medication management E/M services would be documented per the medical E/M criteria. Level of service could be assigned by the time or MDM criteria outlined in the waivers.
Documentation of diagnosis(es)
Provider signature with credential
Reminder – Group therapy is not eligible for telehealth
Tele-Dentistry
bkd.com/COVID‐HC
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› State of Illinois, Provider Notice 5/5/2020, “Teledentistry Services Prompted by COVID-19” and Provider Notice 3/30/2020, “Telehealth Expansion Billing Instructions”
› Dental evaluations may be rendered through combination of audio and visual means. Either synchronous or asynchronous may be rendered virtually
› Service “must be of an amount and nature sufficient to meet the key components and requirements of the same service when rendered via face-to-face interaction” and be “in accordance with the code definitions, in conjunction with D0140-Limited Oral Evaluation”
› “Properly document and chart any telehealth appointments, either electronically or by some other means, to ensure this information is added to the patient’s dental chart”
• California Dental Association, “Dental Billing and Telehealth/Teledentristy”
What About Dental Tele-Visits?
› Preferred that dental providers utilize audiovisual technology to conduct problem focused dental evaluations
› Assess the patient’s presenting complaints to determine if telecommunication or virtual technology will be sufficient to care for the patient
› Is the scenario urgent or emergent?› Have you documented the specific problem, dental emergency,
trauma, or acute infection?› Is this an encounter for case management?
American Dental Association (ADA)
bkd.com/COVID-HC
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› Is intake paperwork completed and housed in dental record• Patient intake• Informed consent• Medical/dental history forms obtained for new patients
› Can images sent from the patient or taken during the examination be saved in the electronic dental record?
› Are you able to update information in the electronic dental record in order to record the virtual service?
American Dental Association (ADA)
bkd.com/COVID-HC
State of Illinois – Tele-dentistry Codes
• As per Provider Notice 5/5/2020, “Teledentistry Services Prompted by COVID-19”, the following codes will be accepted
• Encounter clinics “must add D0999 to the first line of the claim with Place of Service of 02”
• https://success.ada.org/~/media/CPS/Files/COVID/ADA_COVID_Coding_and_Billing_Guidance.pdf
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E-Visits or E-Checks
This Photo by Unknown Author is licensed under CC BY-SA
Documentation for E-Checks and E-Visits
• Method of communication
• Patient demographics
• Reason for contact
• Content of discussion
• Resolution/orders/scheduling
• Time (start/stop)
• Signature
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COVID-19 ICD-10-CM Documentation
› COVID-19 is a virus
› Formal virus name:• Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2)• 2019 novel coronavirus (nCoV)• COVID-19 virus
› The disease is named• Coronavirus disease 2019 (COVID-19)
It’s All in the Word(s)
Source: https://www.cdc.gov/nchs/data/icd/COVID-19-guidelines-final.pdf
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› Clinical documentation should clearly reflect the reason for the encounter including whether or not the patient is asymptomatic but needs/wants to be screened
› Patient would have no known exposure› Test results are negative or unknown› Was the condition ruled out?› Assign ICD-10 Z11.59
Z Codes – Asymptomatic, Screening for COVID-19
Source: https://www.cdc.gov/nchs/data/icd/COVID-19-guidelines-final.pdf
› Clinical documentation should clearly reflect presenting signs and symptoms that might be associated with COVID-19, such as:
• Cough• Shortness of breath• Fever
› Assign the ICD-10 codes for the documented signs/symptoms› If the patient relays a known contact or exposure to someone
with COVID-19, also assign ICD-10 Z20.828
Z Codes – Symptomatic, Not Confirmed
Source: https://www.cdc.gov/nchs/data/icd/COVID-19-guidelines-final.pdf
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› Clinical documentation should clearly reflect the reason for the encounter as well as historical information
› Has there been a possible exposure? › Was the condition ruled out?› Assign ICD-10 Z03.818
Z Codes – Suspected COVID-19
Source: https://www.cdc.gov/nchs/data/icd/COVID-19-guidelines-final.pdf
› Clinical documentation should clearly reflect the reason for the encounter and historical information
› Has there been an actual exposure? Was the exposure resulting from contact with another person who has confirmed COVID-19 or is suspected to have COVID-19? Document as many details as possible to assist with tracking.
› Has your patient tested negative?› Has your patient not received test results?› Assign ICD-10 Z20.828
Z Codes – Actual Exposure to COVID-19
Source: https://www.cdc.gov/nchs/data/icd/COVID-19-guidelines-final.pdf
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› Clinical documentation –• Confirmed diagnosis must be documented in the medical record by the provider
• Medical record should also contain laboratory report with positive results; or• A presumptive positive COVID-19 test result
› Positive test for the virus at the local or state level› CDC confirmation is not required
• If the provider documents a “rule out”, “suspected,” “possible,” “probable,” or “inconclusive,” do not code positive results
› The reason for the visit would be coded
• It is recommended that coding occur after test results are available to reduce coding error(s) and inaccurate statistical data
U07.1 – Confirmed COVID-19
Source: https://www.cdc.gov/nchs/data/icd/COVID-19-guidelines-final.pdf
› Clinical documentation should clearly reflect the reason for the encounter and historical information
› The patient may present with signs/symptoms associated with not only COVID, but other respiratory illness so several laboratory tests are ordered
› COVID test results are negative, but influenza result is positive› Assign primary code for the positive influenza› Assign a secondary code Z20.828
Screening Result Positive for Other Respiratory Illness
Source: AHA Coding clinic
6/30/2020
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ICD-10-CM Code Description Scenario List on the Claim Form as:
Z03.818 Observation for suspected exposure
Patient presents with possible exposure
First-listed code
Z20.828 Contact with and suspected exposure
Patient presents with a history of suspected exposure or known exposure, or has unknown test results
First-listed code
Z11.59 Screening Patient is asymptomatic or has had negative or unknown test results
First-listed
U07.1 COVID-19 Laboratory testing results/provider documentation of confirmed COVD-19. Not used for rule-outs.
First-listed
ICD-10-CM Code Description Scenario List on the Claim Form as:
Assign codes for presenting signs and symptoms:
Examples:R05 CoughR06.02 Shortness of breathR50.9 FeverObservation for suspected exposureContact with and suspected exposure
Patient presents with active signs/symptoms without a definitive diagnosis of COVID-19) or negative diagnosis (i.e., Influenza)
First-listed code if no additional screening or testing is ordered/performed.If testing is performed, then a secondary diagnosis code is assigned for known or suspected exposure
O98.5X Viral disease(s) complicating pregnancy
Patient presents with known pregnancy with positive COVID-19
Obstetric code is first-listed.U07.1 is listed as secondary in addition to any other manifestation codes
Thi Ph t b U k A th i li d
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Additional Resources
• State of Illinois• Joint Committee on Administrative Rules, Administrative Code, Title 89: Social Services,
Chapter I: Department of Healthcare and Family Services Subchapter d: Medical Programs, Part 140 Medical Payment Section 140.403 Telehealth Services (State of Illinois)
• Illinois Health and Hospital Association (IHA), “IHA COVID-19 Telehealth Update #1: State Coverage and Reimbursement”’, April 1, 2020
• Alkerman LLP, “Illinois Telehealth Updates,” March 25, 2020, Amy Jeon McCullough, Sidney Welch
› Industry• American Health Information Management Association (AHIMA), Telemedicine Toolkit, 2017
• American Academy of Family Physicians (AAFP), “Inside Look at Using Telemedicine During COVID-19 Pandemic”, March 23, 2020, Chris Crawford
• The Doctors Company, “COVID-19 Telehealth Resource Center”, April 16, 2020
• American College of Radiology (ACR), “CMS Defines Terms for Telehealth Use During COVID-19 Crisis”, April 1, 2020
• American Dental Association (ADA), “COVID-19 Coding and Billing Interim Guidance: Virtual Visits”, May 11, 2020
• American Hospital Association (AHA-, “ICD-10-CM Coding for COVID-19”, April 1, 2020, Nelly Leon-Chisen, RHIA, Executive Editor Coding Clinic Publications, Director of Coding and Classification