Ensuring Compliance in Telehealth Billing: Documentation is key!

In the realm of telehealth billing, documentation is key. This next article in our series serves as a reminder of the importance of accurate documentation and decision-making in billing, specifically regarding Level B, C, D and E consultations. It is designed to guide Australian General Practitioners through the nuances of billing compliance while emphasising the importance of good clinical practice.

In January 2023, a significant Professional Services Review (PSR) case highlighted ongoing compliance issues with Level B consultations. As mentioned in the previous article, form November 1st 2023, the item numbers are significantly aligned across a level B:  face to face (Item 23) or Telephone (91891) or Telehealth (video 91800), being a 6 minute minimum and requiring the key elements of a Level B consultation. The key elements are that it is: greater than 6 minutes and usually less than 20 minutes (although this depends on the complexity. Just because the consultation is long, if it doesn’t meet the level B complexity, then it is still only a level A consultation! More on this later in the series.) It is also be ‘not obvious or straightforward’. Finally, it must include ‘some or all’ of clinically relevant history, examination, investigation, management and preventative health.

This PSR case (and the $400K payback from the practitioner to Medicare for the inappropriately documented consultations billed), underscores the importance of being meticulous in both your clinical notes and in determining the appropriate item number for billing. The key questions for the practitioner are ‘what did I do’ and then ‘what did I document’? 

If we write “Telephone consult, script for anti-hypertensives requested. Script sent to pharmacy’, it reads like a ‘simple and straightforward’ consult, ie level A. On the other hand, we might have done all the things we usually do in a consultation and documented as: “Telephone consultation- Start time 14.02, End time 14.10. Problem: Hypertension. Patient has been measuring BP at home. Measures average systolic in 130s. Today is well with no medication side effects. Discussion re associated cardiac risks: Lipids due in December, form done. Last weight on record is BMI 28. Encouraged exercise and review weight at next consultation”. Of course we would all approach this consultation differently, but these notes definitely show a consultation that is not a ‘simple and straightforward’ problem, and would qualify as a level B telephone consultation.

The balancing act between fearing audits and underbilling versus overbilling can be challenging. The majority of GPs, when uncertain, tend to underbill for their services. The emphasis here is not to instil fear but to encourage GPs to claim appropriately for the good clinical services they provide. By being up-to-date and documenting thoroughly, you can be confident in your billing practices.

When an audit occurs, the primary focus is on the documentation, not on the possibility of a verbal explanation of your services. Audits are generally document-based reviews, where your clinical notes are examined for compliance with billing regulations. For rural or regional GPs, verbal discussions may occur only in the context of the 80/20 rule, which examines high volume in a small community setting. 

Templates can be a valuable tool for GPs, but it's essential that they are used judiciously. Templates should serve as a prompt for comprehensive note-taking rather than a one-size-fits-all solution. Ensure that your clinical notes accurately reflect the patient's individual condition and that templated text doesn't contradict your patient’s medical condition as documented in your clinical notes or duplicate information from other patients.

In summary, documentation is your strongest ally in an audit. It's not only critical for compliance but also for ensuring continuity of care. Notes must be clear, legible, and detailed enough that another GP could continue care seamlessly based on your records—whether they are handwritten notes scanned into a system or entered directly into an electronic medical record.

Mastering Medical Billing

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