clearing the fog - covid-19 telemedicine clinical documentation … · 2020-07-01 · documentation...

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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.

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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


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


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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)



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


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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


› 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

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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)

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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


› 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


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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


› 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


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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


› 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

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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

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Thank You!

Marla Dumm, CPC, CCS-P, CRCManaging [email protected]

bkd.com/COVID-HC

clearing the fog - covid-19 telemedicine clinical documentation … · 2020-07-01 · documentation...

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