tci Medicare Compliance & Reimbursement - 2020 Issue Q3

Add These Items to Your Telehealth Notes

It’s critical that you guarantee your telehealth and phone visits measure up during provider audits. You must ensure that the following documentation points are included in your records, advised Scott Kraft, CPC, CPMA, senior compliance consultant with Doctors Management. For Audio-Only Visits (Where 99441-99443 Are Typically Reported): Documentation that the patient consented to an audio-only visit. Documentation of the type of visit, and clear documen­tation that the visit was audio only. Detail of what was discussed. Specific documentation of time spent. “If there’s no time documented for an audio encounter, there’s nothing to support...

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