Telehealth Visit Documentation – MAC

Increased scrutiny has already been seen around telehealth visits for states under Review Choice

Demonstration. The main issue has been the physician either has not conducted the face-to-face visit with both audio and video or they may have but their documentation does not support that. If an agency is denied payment on one 30-day period due to the face-to-face they will be at risk for getting every 30-day period denied. 

Ways to avoid common face-to-face errors include making sure that before the claim is billed that the physician face-to-face includes documentation that it was done with audio and video. In addition, make sure that the encounter and the chief complaint align with the certification and Plan of Care primary diagnosis and focus of care. Lastly ensure that the Oasis coding matches the encounter content. 

Remember that telehealth visits must be included in the patients Plan of Care. CMS requires that telehealth visits with frequency, interventions and goals be included in the Plan of Care as well as why the visit was being conducted via telehealth. 

Finally, remember that telehealth visits for Home Health are not included in the total number of visits towards the LUPA thresholds. 

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