While telehealth increases access to care for many, it also opens many possibilities for fraud, waste, and abuse (FWA), whether intentional or otherwise. Some providers might just struggle with the muscle memory of old coding structures, forgetting or neglecting to add proper documentation that becomes a necessity with new updates. But there’s also plenty of room for bad actors looking for opportunities, possibly taking advantage of telehealth services through various schemes involving anything from place of service or inappropriate documentation.
This year, the Centers for Medicare & Medicaid Services (CMS) has made changes to telemedicine guidelines and policies, as well as to documentation requirements for providers who utilize telemedicine to deliver care to their patients. This set of changes mostly impacts audio-only telehealth efforts, including:
Clarifications related to these changes include:
Amid these audio-only telehealth updates, potential FWA could come up during the medical record audit in a variety of ways, most likely in the documentation. With the absence of audio-only codes, providers will be responsible for noting the type of communication with the patient in order to clarify how care was provided. For example, a provider might adjust to the lack of audio-only codes incorrectly, perhaps by calling a patient via telephone after a failed audio-visual connection but neglecting to document it properly in their notes. This could potentially lead to inappropriate reimbursement.
Many cases also relate to place of care or to time. Without proper documentation, it can be unclear where care took place, whether services are being double-billed (both in-office and telehealth), or for how long care took place, since telehealth services are typically provided in a vacuum.
While these audio-only coding updates are an important safeguard against further inappropriate telehealth coding, plans should stay vigilant to the possibility of improper billing within telehealth overall. The first step for health plans is to ensure they are following the proper documentation requirements for capturing telehealth services starting in 2025, as well as verifying the proper place of service documentation for services rendered. Neglecting to note place of care could open doors for FWA, including over- or under-billing or, in a worst-case scenario, a possibility for billing impossible days, where more services are billed for than there are hours in the day.
In line with checking documentation, plans also need to review all coding updates in the 2025 AMA CPT code book and 2025 HCPCS code book. When performing medical record audits for dates of services starting in 2025, the medical record auditors will need to determine if the proper documentation for telemedicine services is noted in the patient’s medical record that would support the service billed. This could include a fair amount of nuance that might not be detected right away by technology, and requires scrutiny to scan for discrepancies.
The possibilities for telehealth efforts continue to grow and codes and trends continue to evolve to expand care while keeping FWA at bay. Staying on top of the latest changes and documentation requirements requires constant vigilance to ensure a strict adherence to the latest regulatory demands, but it can also be overwhelming. Enlisting the help of a trusted partner can mean the difference between improper coding and accurate billing.
Get help from Cotiviti’s 360 Pattern Review™ to stay on top of emerging schemes in the market and avoid paying for inappropriate claims while protecting your members.