Full text
Department of Health and Human Services
OFFICE OF
INSPECTOR GENERAL
MEDICARE GENERALLY PAID FOR
EVALUATION AND MANAGEMENT SERVICES
PROVIDED VIA TELEHEALTH
DURING THE FIRST 9 MONTHS OF THE
COVID-19 PUBLIC HEALTH EMERGENCY
THAT MET MEDICARE REQUIREMENTS
Amy J. Frontz
Deputy Inspector General
for Audit Services
February 2024
A-01-21-00501
Inquiries about this report may be addressed to the Office of Public Affairs at
Public.Affairs@oig.hhs.gov.
Office of Inspector General
https://oig.hhs.gov
The mission of the Office of Inspector General (OIG) is to provide objective oversight to promote the
economy, efficiency, effectiveness, and integrity of the Department of Health and Human Services (HHS)
programs, as well as the health and welfare of the people they serve. Established by Public Law
No. 95-452, as amended, OIG carries out its mission through audits, investigations, and evaluations
conducted by the following operating components:
Office of Audit Services. OAS provides auditing services for HHS, either by conducting audits
with its own audit resources or by overseeing audit work done by others. The audits examine the
performance of HHS programs, funding recipients, and contractors in carrying out their respective
responsibilities and provide independent assessments of HHS programs and operations to reduce waste,
abuse, and mismanagement.
Office of Evaluation and Inspections. OEI’s national evaluations provide HHS, Congress,
and the public with timely, useful, and reliable information on significant issues. To promote impact,
OEI reports also provide practical recommendations for improving program operations.
Office of Investigations. OI’s criminal, civil, and administrative investigations of fraud and
misconduct related to HHS programs and operations often lead to criminal convictions, administrative
sanctions, and civil monetary penalties. OI’s nationwide network of investigators collaborates with the
Department of Justice and other Federal, State, and local law enforcement authorities. OI works with
public health entities to minimize adverse patient impacts following enforcement operations. OI also
provides security and protection for the Secretary and other senior HHS officials.
Office of Counsel to the Inspector General. OCIG provides legal advice to OIG on HHS
programs and OIG’s internal operations. The law office also imposes exclusions and civil monetary
penalties, monitors Corporate Integrity Agreements, and represents HHS’s interests in False Claims Act
cases. In addition, OCIG publishes advisory opinions, compliance program guidance documents, fraud
alerts, and other resources regarding compliance considerations, the anti-kickback statute, and other
OIG enforcement authorities.
Notices
THIS REPORT IS AVAILABLE TO THE PUBLIC
at https://oig.hhs.gov
Section 8M of the Inspector General Act, 5 U.S.C. App., requires
that OIG post its publicly available reports on the OIG website.
OFFICE OF AUDIT SERVICES FINDINGS AND OPINIONS
The designation of financial or management practices as
questionable, a recommendation for the disallowance of costs
incurred or claimed, and any other conclusions and
recommendations in this report represent the findings and
opinions of OAS. Authorized officials of the HHS operating
divisions will make final determination on these matters.
Report in Brief
Date: February 2024
Report No. A-01-21-00501
The full report can be found at https://oig.hhs.gov/oas/reports/region1/12100501.asp.
Medicare Generally Paid for Evaluation and
Management Services Provided via Telehealth
During the First 9 Months of the COVID-19 Public
Health Emergency That Met Medicare
Requirements
What OIG Found
Physicians and other practitioners that provided E/M services via telehealth
generally complied with Medicare requirements. For 105 of the 110 sampled
E/M services provided via telehealth, providers complied with Medicare
requirements. However, for the remaining five sampled E/M services,
providers did not comply with Medicare requirements. Medicare paid $446
for the five sampled E/M services for which providers did not document or
insufficiently documented the services. We also identified potential
documentation issues in the medical records used to support the sampled
E/M services that we discuss in the Other Matters section of this report.
This report does not have recommendations because providers generally met
Medicare requirements when billing for E/M services provided via telehealth
and unallowable payments we identified resulted primarily from clerical
errors or the inability to access records.
CMS elected not to provide comments on our draft report.
Why OIG Did This Audit
In response to the COVID-19 public
health emergency (PHE), CMS
temporarily expanded access to health
services provided via telehealth. From
March 2020 through November 2020
(audit period), Medicare Part B paid
approximately $10.3 billion for
Evaluation and Management (E/M)
services, including telehealth services,
provided to Medicare enrollees
nationwide. The telehealth expansion
increased the risk of inappropriate
payments in the Medicare program due
to the extent and speed of the changes.
Therefore, CMS’s oversight of the
telehealth expansion becomes
increasingly important to ensure that
enrollees receive the appropriate quality
of care both during and after the PHE,
while protecting the Medicare program
from fraud, waste, and abuse.
Our objective was to determine whether
physicians and other practitioners that
provided E/M services via telehealth
complied with Medicare requirements.
How OIG Did This Audit
Our audit covered $1.4 billion in
Medicare Part B payments for more than
19 million E/M claim line services that
were billed with place of service codes or
modifiers indicating telehealth was used
to provide the service our audit period.
We selected a stratified random sample
containing three strata of E/M services
provided via telehealth during the audit
period. One stratum included 30 E/M
services billed as telehealth services
provided to new patients and the other
two strata each included 40 E/M services
billed as telehealth services provided to
established patients.
Medicare Payments for Telehealth E/M Services During the First 9 Months of COVID (A-01-21-00501)
TABLE OF CONTENTS
INTRODUCTION ............................................................................................................................ 1
Why We Did This Audit ...................................................................................................... 1
Objective ............................................................................................................................ 1
Background ........................................................................................................................ 2
The Medicare Program ........................................................................................ 2
COVID-19 Public Health Emergency and Expansion of Access to Telehealth ...... 2
The Medicare Physician Fee Schedule ................................................................. 3
Evaluation and Management Services ................................................................. 3
Billing Medicare for Evaluation and Management Services Provided via
Telehealth .......................................................................................................... 4
Documentation of Evaluation and Management Services .................................. 5
Prior Office of Inspector General Work ............................................................... 7
How We Conducted This Audit ......................................................................................... 8
FINDING........................................................................................................................................ 8
Providers Generally Met Medicare Requirements When Billing for Evaluation and
Management Services Provided via Telehealth ............................................................. 9
CONCLUSION ................................................................................................................................ 9
OTHER MATTERS: POTENTIAL DOCUMENTATION ISSUES ......................................................... 10
Potential Documentation Issues Related to Evaluation and Management Services ...... 10
Potential Documentation Issues Related to Telehealth ................................................. 11
APPENDICES
A: Audit Scope and Methodology ............................................................................. 14
B: Evaluation and Management Current Procedural Terminology Codes and
Descriptions .......................................................................................................... 16
C: Related Office of Inspector General Reports ........................................................ 17
D: Statistical Sampling Methodology ........................................................................ 18
E: Sample Results ....................................................................................................... 20
Medicare Payments for Telehealth E/M Services During the First 9 Months of COVID (A-01-21-00501)
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INTRODUCTION
WHY WE DID THIS AUDIT
The COVID-19 pandemic caused unprecedented challenges for providing and receiving
in-person health care as well as significant health and safety concerns. In response to the
COVID-19 public health emergency (PHE), in March 2020, Congress and the Secretary of Health
and Human Services (HHS) authorized the Centers for Medicare & Medicaid Services (CMS) to
temporarily implement waivers and modifications to Medicare program requirements. These
changes expanded access during the PHE to health services provided via telehealth (using
remote communications technologies) by temporarily eliminating or revising some of the
requirements for these services.1 The waivers and modifications provided more options for
people enrolled in Medicare to receive services provided via telehealth, such as evaluation and
management (E/M) services, in the face of the PHE’s challenges.
Previously, Medicare could only pay for telehealth on a limited basis to support rural access to
care services. As a part of the telehealth expansion, CMS covered additional services,
additional distant and originating site locations, and video technology. This helped ensure that
Medicare enrollees were able to receive services from their homes without having to visit an
office or hospital, which could have put them and others at risk. This also allowed a wider
range of providers to offer telehealth services to patients. The additional telehealth services
included E/M services performed by physicians and other practitioners via interactive audio and
video telecommunications systems or audio-only to assess and manage an enrollee’s health.
We conducted this nationwide audit of E/M services because of the significant increase in E/M
services billed as telehealth services during the PHE. During our audit period, from March 1,
2020, through November 30, 2020, Medicare Part B paid approximately $10.3 billion for E/M
services, including $1.4 billion in services provided via telehealth, for Medicare enrollees
nationwide. Our analysis determined that 14 percent of the total amount that Medicare paid
for E/M services provided during our audit period was for telehealth services (compared with
less than 0.1 percent from March 1, 2019, through November 30, 2019).
OBJECTIVE
Our objective was to determine whether physicians and other practitioners that provided E/M
services via telehealth complied with Medicare requirements.
1 The PHE ended May 11, 2023. In response to the Consolidated Appropriations Act, 2023, CMS has already made
some of these temporary waivers and modifications permanent and has extended flexibilities for Medicare
coverage of payment for telehealth services through Dec. 31, 2024.
Medicare Payments for Telehealth E/M Services During the First 9 Months of COVID (A-01-21-00501)
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BACKGROUND
The Medicare Program
The Medicare program, established by Title XVIII of the Social Security Act (the Act), provides
health insurance coverage to people aged 65 and over, people with disabilities, and people with
end-stage renal disease. CMS administers the Medicare program. Medicare Part B provides
supplementary medical insurance for medical and other health services, such as outpatient
services, which include E/M services.
COVID-19 Public Health Emergency and Expansion of Access to Telehealth
The PHE created unprecedented challenges in Medicare enrollees’ access to health care
services. In response to the PHE, HHS and CMS took a number of actions to temporarily expand
access to telehealth for Medicare enrollees.2 Telehealth (also known as telemedicine) uses
electronic information and telecommunications technologies to provide care when a health
care provider and enrollee are not in the same physical location. CMS expanded access,
allowing enrollees to use telehealth for a wide range of services and in a wider array of
locations, including urban areas.3
CMS allowed providers to deliver services via telehealth through live-video or audio-only visits.4
In addition, HHS issued a temporary notice to allow providers during the PHE to use any
nonpublic-facing remote communication product that is available to communicate with
patients.5 Although providers could choose to use video communication products that are
2 HHS and CMS were able to temporarily expand access to telehealth because the declaration of the PHE and
national emergency allowed the HHS Secretary to use the waiver authority under section 1135 of the Act. On Mar.
13, 2020, President Trump declared the COVID-19 outbreak a national emergency. The Coronavirus Preparedness
and Response Supplemental Appropriations Act of 2020 and the Coronavirus Aid, Relief, and Economic Security Act
broadened the waiver authority under section 1135 of the Act which allowed HHS and CMS to waive additional
telehealth-related restrictions with a PHE declaration in place.
3 Prior to the PHE, Medicare could only pay for telehealth on a limited basis to support rural access to care
services. These telehealth services were required to be provided through live, interactive audio-video
conferencing between an enrollee located at a certified rural originating site (clinic, hospital, or certain other types
of medical facilities for the service; not an enrollee’s home or office) and a practitioner located at a distant site.
See CMS’s “Medicare Telemedicine Health Care Provider Fact Sheet.” Accessed on Apr. 11, 2023.
4 A live-video visit, also referred to as a “real-time” visit, is two-way, face-to-face interaction between a patient and
provider using audiovisual communications technology. An audio-only visit is the use of a telephone without
video.
5 Under this notification, HHS would not impose penalties against covered health care providers for noncompliance
with the HIPAA Rules that relates to the good faith provision of telehealth services during the COVID–19
nationwide public health emergency (85 Fed. Reg. 22024 (Apr. 21, 2020)). HHS, “Notification of Enforcement
Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency.”
Accessed on Apr. 11, 2023.
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Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliant and
provide additional privacy protections, they were not required to do so during the PHE.
The Medicare Physician Fee Schedule
Under Medicare Part B, Healthcare Common Procedure Coding System (HCPCS) codes,6, 7
Current Procedural Terminology (CPT) codes,8 modifiers, and their descriptions are used for the
purpose of reporting physicians’ services. Reimbursement rates for physician’s services are
based primarily on CMS’s Medicare Physician Fee Schedule and the rates for each respective
procedure code vary depending on the relative value and geographic location of the service.9
Additional rate adjustments may be made based upon payment modifiers.
Evaluation and Management Services
E/M services are visits covered under Medicare Part B and performed by physicians and
nonphysician practitioners (hereinafter, collectively referred to as providers) to assess and
manage an enrollee’s health.10 E/M services are divided into broad categories that reflect the
type of service, the place of service, and the patient’s status (i.e., new or established patient).
The Medicare Claims Processing Manual (the Manual) states that documentation should
support the level of service reported (Pub. No. 100-04, chapter 12, § 30.6.1 (A)).11 In addition,
the Act § 1833(e) states that no payment shall be made to any provider of services or other
6 HCPCS codes are a collection of standardized codes that represent medical procedures, supplies, products, and
services. The codes are used to facilitate the processing of health insurance claims by Medicare and other
insurers.
7 HCPCS codes are divided into two primary groups: level I and level II. Level I HCPCS codes consist of five-
character all numeric CPT codes that are maintained by the American Medical Association (AMA) and used
primarily to identify medical services and procedures furnished by physicians and other health care professionals.
Level II HCPCS codes consist of five-character alpha-numeric codes that are primarily used to report items and
nonphysicians’ services not included in the CPT codes. Our audit relates to the Level I HCPCS/CPT codes for E/M
services, which we refer to as “procedure codes” for reporting purposes.
8 The five-character codes and descriptions included in this report are obtained from Current Procedural
Terminology (CPT®), copyright 2019–2020 by the AMA. CPT is developed by the AMA as a listing of descriptive
terms and five character identifying codes and modifiers for reporting medical services and procedures. Any use
of CPT outside of this report should refer to the most current version of the Current Procedural Terminology
available from AMA. Applicable FARS/DFARS apply.
9 The Act § 1848(a)(1) establishes that Medicare Part B payments for physicians’ services shall be made based on
the lesser of the actual charge or the applicable fee schedule amount for the services.
10 Nonphysician practitioners are health care providers (e.g., nurse practitioners, clinical nurse specialists, and
physician assistants) who practice either in collaboration with a physician or under the supervision of a physician.
11 Rev. 11842 moved this statement to § 30.6.1(B) effective Jan. 1, 2023.
Medicare Payments for Telehealth E/M Services During the First 9 Months of COVID (A-01-21-00501)
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person unless there has been furnished such information as may be necessary to determine the
amounts due such provider.
Providers bill Medicare for individual E/M services using 1 of 10 E/M CPT codes for office visits,
depending on the complexity of the medical decision making or the time spent with the patient
and whether the office visit is with a new or established patient.12 Providers may select one of
five E/M service levels for both new and established patients based on either the level of
complexity of medical decision making or the time spent with the patient. For instance, if
providers decide to select E/M CPT codes to bill E/M services based on the level of complexity
of medical decision making, they may select higher level E/M CPT codes when the complexity of
establishing a diagnosis or selecting a management option is higher. In addition, if providers
decide to select E/M CPT codes to bill E/M services based on the time spent with the patient,
the time defined in the service descriptors is used for selecting the appropriate level E/M CPT
codes.13
An office visit with a new patient can be billed using one of five E/M CPT codes, from 99201
(the lowest complexity level or time spent code) to 99205 (the highest complexity level or time
spent code).14 An office visit with an established patient can be billed using one of five E/M CPT
codes, from 99211 (the lowest complexity level or time spent code) to 99215 (the highest
complexity level or time spent code). Appendix B shows the E/M CPT codes and their
descriptions.
Billing Medicare for Evaluation and Management Services Provided via Telehealth
Although telehealth services were paid at the same rate as in-person services during the PHE,
CMS revised the Medicare billing guidance for telehealth services. To bill Medicare for an E/M
service provided via telehealth before March 1, 2020, a provider was required to include place
of service code 02 on the claim to indicate that the service was provided through
telecommunication technology.15 To bill Medicare for E/M services provided via telehealth
with dates of services on or after March 1, 2020, and for the duration of our audit period,
providers should have submitted claims that included the place of service code that would have
12 The Secretary adopted the CPT, Fourth Edition (CPT-4) as the standard medical data code set, maintained and
distributed by the AMA for physician services, for the period on and after Oct. 1, 2015 (45 CFR §§ 162.1002(a)(5)
and 162.1002(c)(1)).
13 Beginning on Mar. 1, 2020, time alone can be used to select the appropriate code level for the office or other
outpatient E/M CPT codes.
14 Beginning Jan. 1, 2021, CPT code 99201 is no longer in use.
15 CMS, Medicare Claims Processing Manual, Pub. No. 100-04, chapter 12, § 190.6.1.
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been billed had the service been provided in-person and added modifier 95 to indicate that the
service was provided via telehealth.16, 17
Providers could have also used the following modifiers listed below to bill for telehealth
services:
• Modifier GT indicates that the critical access hospital method II service was provided via
interactive audio and video telecommunications systems.18
• Modifier GQ indicates that the service was provided via asynchronous (store and
forward) telecommunications systems.19
• Modifier G0 indicates that the service was a telehealth service provided for purposes of
diagnosis, evaluation, or treatment of symptoms of an acute stroke.
Documentation of Evaluation and Management Services
CMS has issued guidelines for physicians to use when determining and documenting the
appropriate level of an E/M service. These guidelines outline what information is necessary to
include in the medical record to support the level of an E/M service. There are two versions of
the documentation guidelines, the 1995 Documentation Guidelines for Evaluation and
Management Services (1995 E/M documentation guidelines) and the 1997 Documentation
Guidelines for Evaluation and Management Services (1997 E/M documentation guidelines).
The 1995 and 1997 E/M documentation guidelines outline the general principles of
documentation that are applicable to all types of medical and surgical services in all settings.
For E/M services, the nature and amount of physician work and documentation varies by type
of service, place of service, and the patient’s status. E/M documentation should generally
16 85 Fed. Reg. 19230, 19233 (Apr. 6, 2020); CMS’s Medicare Learning Network (MLN) Matters No. SE20011
(Sept. 8, 2021).
17 A modifier is a two-character code reported with a HCPCS or CPT code and is used to give Medicare additional
information needed to process a claim (National Correct Coding Initiative Policy Manual for Medicare
Services, chapter I, § E(1) and Medicare Claims Processing Manual, chapter 23, § 20.3).
18 A critical access hospital is a hospital certified under a specific set of Medicare conditions of participation, which
are structured differently than the acute-care hospital conditions of participation. A critical access hospital may
elect the method II payment option for outpatient professional services, which allows the hospital to be paid
115 percent of what it would otherwise be paid under the Medicare fee schedule.
19 For Federal telemedicine demonstration programs conducted in Alaska or Hawaii, asynchronous store-and-
forward technologies may be used as a substitute for an interactive telecommunications system (42 CFR
§ 410.78(d)). These technologies transmit a patient’s medical information from an originating site to a provider at
a distant site (42 CFR § 410.78(a)(1)).
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conform to the following general principles, taking into account variable circumstances in
providing E/M services:
1. The medical record should be complete and legible.
2. The documentation of each patient encounter should include: reason for encounter and
relevant history, physical examination findings, and prior diagnostic test results;
assessment, clinical impression, or diagnosis; plan for care; and date and legible identity
of the observer.
3. If not documented, the rationale for ordering diagnostic and other ancillary services
should be easily inferred.
4. Past and present diagnoses should be accessible to the treating or consulting physician.
5. Appropriate health risk factors should be identified.
6. The patient’s progress, response to and changes in treatment, and revision of diagnosis
should be documented.
7. The CPT codes reported on the health insurance claim form should be supported by the
documentation in the medical record.
The 1995 and 1997 E/M documentation guidelines and the American Medical Association’s
(AMA’s) 2020 AMA CPT Codebook Evaluation and Management Services Guidelines (AMA CPT
Codebook guidelines) levels of E/M services section states that the descriptors for the levels of
E/M services recognize seven components. These seven components are: (1) History, (2)
Examination, (3) Medical decision making, (4) Counseling, (5) Coordination of care, (6) Nature of
presenting problem, and (7) Time.
The 2020 Physician Fee Schedule Final Rule (84 Fed. Reg. 62568, 62844 (Nov.15, 2019)) stated
that effective January 1, 2020, when coding and billing E/M visits to Medicare, providers may
use one of two versions (the 1995 or 1997 E/ M documentation guidelines) for a patient
encounter. Further, this Final Rule explains that these guidelines specify the medical record
information within each of the three key components (such as number of body systems
reviewed) that serves as support for billing a given level of E/M service. The Final Rule explains
that the 1995 and 1997 guidelines are very similar to the guidelines for E/M visits that are
currently located within the AMA CPT Codebook guidelines. For example, the core structure of
what comprises or defines the different levels of history, exam, and medical decision making in
the 1995 and 1997 E/M documentation guidelines are the same as those in the CPT codebook.
However, the Final Rule explains that the 1995 and 1997 E/M documentation guidelines include
extensive examples of clinical work that comprise different levels of medical decision making
that do not appear in the AMA CPT Codebook guidelines. Also, the 1995 and 1997 E/ M
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documentation guidelines do not contain references to preventive care that appear in the AMA
CPT Codebook guidelines.
This Final Rule also stated that effective January 1, 2021, providers could choose to document
E/M services using medical decision making or time, or providers could use the current
framework based on the 1995 or 1997 E/M documentation guidelines (84 Fed. Reg. at 62846).
In addition, the Interim Final Rule regarding the response to the PHE effective March 1, 2020,
made payment, policy, and programmatic changes intended to give providers flexibilities
needed to respond effectively to the PHE. For example, the level of service for office outpatient
visits furnished via telehealth may be based on time or medical decision making. Finally,
documentation requirements for history and physical exam have been removed for office
outpatient visits furnished via telehealth. CMS explained that this policy is similar to the policy
that applied to E/M services beginning in 2021 under policies finalized in the 2020 Physician Fee
Schedule Final Rule (85 Fed. Reg. 19230, 19269 (Apr. 6, 2020)).
The 2020 Physician Fee Schedule Final Rule and the Interim Final Rule regarding the response to
the PHE changed how providers select the appropriate level of E/M services. The following
year, the 2021 AMA CPT Codebook guidelines were updated to clarify that providers may select
the appropriate level of E/M services based on the following:
• the level of the medical decision making as defined for each service, or
• the total time for E/M services performed on the date of the encounter.
Medicare Learning Network’s (MLN’s) Evaluation and Management Services Guide, ICN 006764
(January 2020), provides education and reminds providers that the medical records should be
complete and legible and states: “If it is not documented, it has not been done.”
Prior Office of Inspector General Work
OIG has issued several reports on telehealth services provided during the PHE. For example, for
one study, we developed 7 billing measures that may indicate fraud, waste, or abuse in
telehealth services (e.g., billing a high average number of hours of telehealth services per visit)
and identified more than 1,700 health care providers whose billing for telehealth services
during the first year of the COVID-19 pandemic posed a high risk to Medicare. We determined
that all of these providers warrant further scrutiny because they may have billed for telehealth
services that were not medically necessary or were never provided.20 These providers billed for
telehealth services (e.g., office visits) for about half a million Medicare enrollees and received a
total of $127.7 million in Medicare fee-for-service payments. Another study found that more
than 2 in 5 Medicare enrollees used telehealth services during the COVID-19 pandemic, and
enrollees used 88 times more telehealth services during the first year of the pandemic
20 Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks (OEI-02-20-00720),
Sept. 7, 2022.
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(March 2020 through February 2021) than they used in the prior year.21 See Appendix C for a
list of related OIG reports.
HOW WE CONDUCTED THIS AUDIT
Our audit covered $1.4 billion in Medicare Part B payments for more than 19 million E/M claim
lines of services (E/M services) that were billed with place of service codes or modifiers
indicating telehealth was used to provide the service during the first 9 months that access to
telehealth was expanded (our audit period, from March 2020, through November 2020). We
selected a stratified random sample containing three strata of E/M services provided via
telehealth during the audit period.22
We requested supporting documentation from the providers for E/M services included in our
sample. We reviewed the supporting documentation to determine whether providers met
Medicare requirements, guidelines, and guidance when billing for E/M services provided via
telehealth. However, we did not determine whether the services were medically necessary or
assess the quality of care provided to enrollees. We also reviewed the supporting
documentation to obtain information on how providers documented telehealth services
provided during our audit period. Finally, we reviewed the E/M documentation guidelines,
2020 Physician Fee Schedule Final Rule, the Interim Final Rule regarding the response to the
PHE, and AMA guidelines.
We conducted this performance audit in accordance with generally accepted government
auditing standards. Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions
based on our audit objectives. We believe that the evidence obtained provides a reasonable
basis for our findings and conclusions based on our audit objectives.
Appendix A contains details of our audit scope and methodology, Appendix D contains details
of our statistical sampling methodology, and Appendix E contains our sample results.
FINDING
Physicians and other practitioners that provided E/M services via telehealth generally complied
with Medicare requirements. For 105 of the 110 sampled E/M services provided via telehealth,
providers complied with Medicare requirements. However, for the remaining five sampled E/M
services, providers did not comply with Medicare requirements. Medicare paid $446 for the
five sampled E/M services for which providers did not document or insufficiently documented
the services.
21 Telehealth Was Critical for Providing Services to Medicare Beneficiaries During the First Year of the COVID-19
Pandemic (OEI-02-20-00520), Mar. 15, 2022.
22 To identify E/M services that were billed as telehealth services, we identified claim lines that included telehealth
indicators (i.e., place of service code 02 or with modifiers GT, GQ, G0, or 95).
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We also identified potential documentation issues in the medical records used to support the
sampled E/M services that we discuss in the Other Matters section of this report.
PROVIDERS GENERALLY MET MEDICARE REQUIREMENTS WHEN BILLING FOR EVALUATION
AND MANAGEMENT SERVICES PROVIDED VIA TELEHEALTH
For 5 of the 110 Medicare Part B paid claims for E/M services provided via telehealth in our
stratified random sample, the providers did not comply with Medicare requirements.23
Specifically:
• For one of the sample items, the medical record documentation provided was
insufficiently detailed to support the billed service.24
• For two of the sample items, the providers stated that no medical record
documentation could be provided to support the billed service.
• For two of the sample items, the providers did not submit the medical record
documentation to support the billed service despite repeated requests for the records.
The reasons that the E/M services provided via telehealth were not documented or were
insufficiently documented were: one provider provided insufficient detail in the medical
record, one provider stated the service was billed in error, one provider stated it no longer had
access to the record, and two providers did not submit the medical record documentation
despite repeated requests for the records.
Medicare paid $446 for the five sampled E/M services for which providers did not meet
Medicare requirements.
CONCLUSION
This report does not have recommendations because providers generally met Medicare
requirements when billing for E/M services provided via telehealth and unallowable payments
we identified resulted primarily from clerical errors or the inability to access records. We
23 We did not conduct medical review to determine whether the E/M services were coded at the correct level of
service, and we did not review for medical sufficiency. Since we did not use medical review, we assumed that the
services performed were medically necessary provided that the information necessary to support the E/M services
was reflected in the medical records.
24 Most of the medical records we reviewed contained detailed notes. However, for this sample item, we were
unable to verify whether the medical record supported the billed service because the documentation provided to
us was mostly illegible and contained little detail (i.e., only a one-page medical record was provided with a few
hand-written lines). As a result, we determined that the provider did not furnish information necessary to support
the claim as required by the Act § 1833(e).
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provided CMS with the details for the five sampled E/M services for which providers did not
meet Medicare requirements so they can decide how to resolve them.
CMS elected not to provide comments on our draft report.
OTHER MATTERS: POTENTIAL DOCUMENTATION ISSUES
We identified potential documentation issues in the medical records used to support the
sampled E/M services. Some of these documentation issues were specific to E/M services in
general, and other documentation issues were specific to telehealth. The potential
documentation issues specific to E/M services occurred because CMS has not updated the 1995
and 1997 E/M documentation guidelines or issued new guidelines to reflect the most recent
changes announced in the Federal Register or existing Medicare guidance. The potential
documentation issues specific to telehealth occurred because CMS has not finalized the
requirements for services provided via telehealth and, therefore, has not issued guidance for
the documentation of telehealth. Although these issues do not currently have an effect on
Medicare payments and this report does not contain recommendations related to these
potential documentation issues,25 this information may be beneficial to CMS as it considers
updating existing documentation guidelines or issuing new guidelines for both E/M services and
telehealth (after the permanent telehealth requirements are established).
POTENTIAL DOCUMENTATION ISSUES RELATED TO EVALUATION AND MANAGEMENT
SERVICES
We identified potential issues related to the documentation of E/M services. Specifically, these
issues were related to time spent on E/M services, patient status, and provider signatures:
• Some providers did not document within the medical records the time spent with the
enrollees. The Manual states that documentation should support the level of service
reported (Pub. No. 100-04, chapter 12, § 30.6.1 (B)). The 2020 Physician Fee Schedule
Final Rule and the Interim Final Rule regarding the response to the PHE changed the
options that providers could use to select the level of E/M services. Specifically, in
addition to medical decision making the change allowed providers to use time.
However, this change was not reflected in the 1995 and 1997 E/M documentation
guidelines. The inclusion of this change in any new version of the documentation
guidelines CMS issues may help ensure that providers include time spent with the
enrollees within the medical records when appropriate.
• Some providers did not document within the medical records that the enrollee was a
new or established patient. The Manual defines the phrase “new patient” to mean a
patient who has not received any professional services (i.e., E/M services or other face-
25 CMS did not establish different payment rates for CPT codes for E/M services provided through audio-only and
provided in-person.
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to-face services (e.g., surgical procedure)) from the physician or physician group practice
(same physician specialty) within the previous 3 years (the Manual, Pub. No. 100-04,
chapter 12, § 30.6.7(A)). However, CMS did not address documenting patient status in
the Manual or the 1995 and 1997 E/M documentation guidelines. Since payment
amount for E/M services differs depending on whether the patient is new or
established, the inclusion of a requirement to include patient status in the medical
record documentation in any new version of the documentation guidelines CMS issues
may better support billed E/M services.
• Some providers did not sign the medical records. Medicare guidance states that Medicare
requires the person responsible for the Medicare enrollee’s care to authenticate the
services provided. The furnishing provider’s signature on a note (i.e., a medical record)
indicates that the provider affirms the note adequately documents the care provided
(CMS, Medicare Program Integrity Manual, Pub. No. 100-08, chapter 3, § 3.3.2.4).
However, CMS did not address signatures in the 1995 and 1997 E/M documentation
guidelines. The inclusion of this signature requirement in any new version of the
documentation guidelines CMS issues may help ensure that providers comply with the
requirements related to provider signatures.
When guidelines are not updated to include requirements or reflect changes, providers are less
likely to include those elements in the medical records they prepare, and the documentation is
more likely to be inconsistent between providers.
POTENTIAL DOCUMENTATION ISSUES RELATED TO TELEHEALTH
We also identified potential issues related to the documentation of telehealth services.
Specifically, providers often documented limited information in medical records related to
telehealth.
The potential documentation issues were related to in-person services coded as audiovisual
services, audiovisual communication technology, location of service provided, audio-only
services coded as audiovisual services and technology issues. Specifically:
• Some of the providers did not document within the medical records how the services
were provided, whether via telehealth (audio-only or audiovisual) or furnished in-
person. Although this did not affect the payments for these services during our audit
period, if providers’ do not document whether the services were provided using
telehealth or in-person, this may affect CMS and Medicare administrative contractors’
(MAC’s)26 ability to rely on the claims data for these services and may impact future
policy changes if CMS establishes different payment rates for telehealth and in-person
services.
26 CMS uses MACs to, among other things, process and pay claims submitted by providers.
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•
Some of the providers that did indicate that audiovisual technology was used did not
always document which audiovisual communication product (e.g., Zoom) was used.
Therefore, we could not determine whether telehealth services were provided using an
audiovisual communication product that was non-public-facing.27 The lack of
information about which communication products were used may be an issue for
determining HIPAA compliance.
• Some of the providers did not document within the medical record the location of the
provider or enrollee (e.g., provider’s office, provider’s home, or enrollee’s home) when
services were provided via telehealth. This information may be beneficial if Federal
Medicare geographic restrictions for providers or enrollees are implemented in the
future.28
• Some providers documented within the medical records that audio-only technology
(i.e., telephone) was used but billed using an audiovisual service CPT code. The CPT
codes for audio-only E/M services are separate from the CPT codes for office or
outpatient visits that were included in our audit.29 Although providers’ inaccurate
coding of these services as audiovisual when audio-only services were provided did not
affect the payments for these services during our audit period, it may affect CMS and
the MACs’ ability to rely on the claims data for these services and may impact future
policy changes.
• Some providers documented within the medical records that the enrollees encountered
telehealth related technology issues. Specifically, they documented that these enrollees
had unreliable internet connection or lacked access to a device for video. Although the
payments for these services were not affected during our audit period, providers’
inaccurate coding of these services as audio and video when audio-only services were
provided may affect CMS and the MACs’ ability to rely on the claims data for these
services and may impact future policy changes. Guidance could be beneficial to
providers on how to document and code services when technology issues occur.
27 A “non-public facing” remote communication product is one that allows only the intended parties to participate
in the communication. Non-public facing remote communication products include, for example, platforms such as
Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, Whatsapp video chat, Zoom, or Skype.
In contrast, public-facing products such as TikTok, Facebook Live, Twitch, or a public chat room are not acceptable
forms of remote communication for telehealth because they are designed to be open to the public or allow wide
or indiscriminate access to the communication.
28 CMS waived geographic restrictions during the PHE, specifically telehealth originating and geographic site
restrictions for telehealth services and allowed patients located in any geographic area both rural and non-rural.
29 CMS allowed CPT codes 99441 through 99443 for E/M services provided via audio-only with dates of service on
or after Mar. 1, 2020.
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Although the expansion of telehealth services during the PHE improved access to care, it also
contributed to risks and vulnerabilities associated with the services provided via telehealth. We
are raising these issues for CMS to consider when developing future policies related to
Medicare services provided via telehealth.
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APPENDIX A: AUDIT SCOPE AND METHODOLOGY
SCOPE
Our nationwide audit covered $1,375,073,244 in Medicare Part B payments to providers for
E/M services that were billed with CPT codes 99201 through 99205 and 99211 through 99215
and either a place of service code 02 or modifiers 95, G0, GQ, or GT indicating telehealth was
used to provide the service from March 1, 2020, through November 30, 2020 (audit period).
We selected a stratified random sample containing three strata of E/M services provided via
telehealth during our audit period. One stratum included 30 E/M services billed as telehealth
services provided to new patients and the other two strata each included 40 E/M services billed
as telehealth services provided to established patients stratified by provider payment amount.
In total, we selected 110 E/M services for review.
We requested supporting documentation from the providers of E/M services included in our
sample to determine whether providers documented services in compliance with Medicare
requirements and guidance when billing E/M services. We reviewed the E/M services and
telehealth information in the supporting documentation provided. For example, we reviewed
which types of communication products providers used. We did not conduct medical review to
determine if the E/M services were coded at the correct level of service and we did not review
for medical necessity.
Our audit objective did not require an understanding or assessment of the internal control
structures of CMS or the MACs. Rather, we limited our review to those controls that were
significant to our objectives. Specifically, we reviewed CMS’s oversight mechanisms for
processing Medicare claims for E/M services and telehealth services. For example, we obtained
an understanding of CMS’s and the MACs’ system edits and their policies and procedures for
documenting and billing E/M and telehealth services.
We conducted our audit from February 2021 through January 2024.
METHODOLOGY
To accomplish our audit objective, we:
• reviewed applicable Federal laws, regulations, and guidance;
• communicated with CMS officials to gain a better understanding of the Medicare
policies regarding E/M services, including services provided via telehealth;
• analyzed the impact of the telehealth expansion by extracting and comparing data for
E/M services provided via telehealth nationwide in calendar years 2019 and 2020;
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• extracted from CMS’s National Claims History file the Medicare Part B paid claim lines
data for E/M services that were billed with either a place of service code or modifiers
indicating telehealth for the audit period;
• created a sampling frame of 19,570,698 E/M services provided via telehealth totaling
$1,375,073,244;
• selected a stratified random sample of 110 E/M services provided via telehealth
(Appendix D);
• reviewed data from CMS’s Common Working File and other available data for the
sampled E/M services to determine whether the claim lines for the services had been
canceled or adjusted;
• requested supporting documentation from the providers;
• reviewed the supporting documentation to determine whether providers complied with
Medicare requirements when documenting E/M services provided via telehealth; and
• discussed the results of our audit with CMS officials.
We provided our draft report to CMS on January 10, 2024, for review. CMS elected not to
provide comments.
We conducted this performance audit in accordance with generally accepted government
auditing standards. Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions
based on our audit objectives. We believe that the evidence obtained provides a reasonable
basis for our findings and conclusions based upon our audit objectives.
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APPENDIX B: EVALUATION AND MANAGEMENT CURRENT PROCEDURAL TERMINOLOGY
CODES AND DESCRIPTIONS
CPT
Code30 Description
99201
New patient office or other outpatient visit. Straightforward medical decision
making. Usually, the presenting problem(s) are self limited or minor. Typically, 10
minutes are spent face-to-face with the patient and/or family.
99202
New patient office or other outpatient visit. Straightforward medical decision
making. Usually, the presenting problem(s) are of low to moderate severity.
Typically, 20 minutes are spent face-to-face with the patient and/or family.
99203
New patient office or other outpatient visit. Medical decision making of low
complexity. Usually, the presenting problem(s) are of moderate severity. Typically,
30 minutes are spent face-to-face with the patient and/or family.
99204
New patient office or other outpatient visit. Medical decision making of moderate
complexity. Usually, the presenting problem(s) are of moderate to high severity.
Typically, 45 minutes are spent face-to-face with the patient and/or family.
99205
New patient office or other outpatient visit. Medical decision making of high
complexity. Usually, the presenting problem(s) are of moderate to high severity.
Typically, 60 minutes are spent face-to-face with the patient and/or family.
99211
Established patient office or other outpatient visit. Usually, the presenting problem(s)
are minimal. Typically, 5 minutes are spent performing or supervising these services.
99212
Established patient office or other outpatient visit. Straightforward medical decision
making. Usually, the presenting problem(s) are self limited or minor. Typically, 10
minutes are spent face-to-face with the patient and/or family.
99213
Established patient office or other outpatient visit. Medical decision making of low
complexity. Usually, the presenting problem(s) are of low to moderate severity.
Typically, 15 minutes are spent face-to-face with the patient and/or family.
99214
Established patient office or other outpatient visit. Medical decision making of
moderate complexity. Usually, the presenting problem(s) are of moderate to high
severity. Typically, 25 minutes are spent face-to-face with the patient and/or family.
99215
Established patient office or other outpatient visit. Medical decision making of high
complexity. Usually, the presenting problem(s) are of moderate to high severity.
Typically, 40 minutes are spent face-to-face with the patient and/or family.
30 The five-character codes and descriptions included in this report are obtained from Current Procedural
Terminology (CPT®), copyright 2019–2020 by the AMA. CPT is developed by the AMA as a listing of descriptive
terms and five character identifying codes and modifiers for reporting medical services and procedures. Any use
of CPT outside of this report should refer to the most current version of the Current Procedural Terminology
available from AMA. Applicable FARS/DFARS apply.
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APPENDIX C: RELATED OFFICE OF INSPECTOR GENERAL REPORTS
Report Title
Report Number
Date Issued
Home Health Agencies Rarely Furnished Services Via
Telehealth Early in the COVID-19 Public Health Emergency
A-05-21-00026
9/25/2023
Telehealth During 2020 Helped Ensure End-Stage Renal
Disease Patients Received Care, But Limited Information
Related to Telehealth Was Documented
A-05-22-00015
8/1/2023
Montana Generally Complied With Requirements for
Telehealth Services During the COVID-19 Pandemic
A-07-21-03250
5/17/2023
Medicare Improperly Paid Providers for Some
Psychotherapy Services, Including Those Provided via
Telehealth, During the First Year of the COVID-19 Public
Health Emergency
A-09-21-03021
5/2/2023
Illinois Generally Complied With Requirements for
Claiming Medicaid Reimbursement for Telehealth
Payments During COVID-19
A-05-21-00035
12/21/2022
Insights on Telehealth Use and Program Integrity Risks
Across Selected Health Care Programs During the
Pandemic
OEI-02-22-00150
11/30/2022
The IHS Telehealth System Was Deployed Without Some
Required Cybersecurity Controls
A-18-21-03100
9/7/2022
Certain Medicare Beneficiaries, Such as Urban and
Hispanic Beneficiaries, Were More Likely Than Others To
Use Telehealth During the First Year of the COVID-19
Pandemic
OEI-02-20-00522
9/2/2022
Medicare Telehealth Services During the First Year of the
Pandemic: Program Integrity Risks
OEI-02-20-00720
9/2/2022
Telehealth Was Critical for Providing Services to Medicare
Beneficiaries During the First Year of the COVID-19
Pandemic
OEI-02-20-00520
3/15/2022
Most Medicare Beneficiaries Received Telehealth Services
Only From Providers With Whom They Had an Established
Relationship
OEI-02-20-00521
10/18/2021
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APPENDIX D: STATISTICAL SAMPLING METHODOLOGY
SAMPLING FRAME
The sampling frame consisted of 19,570,698 claim lines of E/M services totaling $1,375,073,244
in Medicare Part B provider payments for E/M services that were billed with E/M CPT codes
99201 through 99205 and 99211 through 99215 and either a place of service code 02 or
modifiers 95, G0, GQ, or GT indicating telehealth was used to provide the service. The sampling
frame included E/M services with payments of $20.01 through $199.99 and dates of services
during the audit period.
SAMPLE UNIT
The sample unit was a claim line for an E/M service.
SAMPLE DESIGN AND SAMPLE SIZE
We used a stratified random sample containing three strata. One stratum included 30 E/M
services billed as telehealth services provided to new patients and the other two strata each
included 40 E/M services billed as telehealth services provided to established patients. In total,
we selected 110 E/M services for review, as shown in Table 1.
Table 1: Frame Description and Sample Size
Stratum
Patient Status
Type
E/M Services
Payment
Range
Frame Size
(Number of
E/M Services)
Value of Frame
Sample
Size
1
New Patients
$20.01 to
$199.99
912,166
$97,847,065
30
2
Established
Patients
$20.01 to
$72.65
11,688,901
639,085,544
40
3
Established
Patients
$72.66 to
$199.36
6,969,631
638,140,634
40
Total
19,570,698
$1,375,073,244*
110
* The difference in the total is because of rounding.
SOURCE OF RANDOM NUMBERS
We generated the random numbers using the OIG, Office of Audit Services (OAS), statistical
software.
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METHOD OF SELECTING SAMPLE ITEMS
We sorted the items in each stratum by the Record Link Number31 in ascending order and then
consecutively numbered the items in each stratum. We generated the random numbers in
accordance with our sample design, and we then selected the corresponding frame items for
review.
ESTIMATION METHODOLOGY
We have chosen not to report any estimates of unallowable payments in the sampling frame
because of the low number of unallowable payments found in the sample.
31 This field contains a sequentially assigned number for the claims included in the file and allows the user to tie
children line items to the parent claim.
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APPENDIX E: SAMPLE RESULTS
Table 2: Statistical Sample Summary by Patient Type
Stratum
Patient
Status
Type
Frame Size
(Number
of E/M
Services)
Value of Frame
Sample
Size
Value of
Sample
Number of
Incorrectly
Billed E/M
Services in
Sample
Value of
Unallowable
Payments in
Sample
1
New
Patients
912,166
$97,847,065
30
$2,988
4
$381
2
Established
Patients
11,688,901
639,085,544
40
2,161
1
65
3
Established
Patients
6,969,631
638,140,634
40
3,541
0
0
Total
19,570,698 $1,375,073,244
110
$8,691*
5
$446
* The difference in total is because of rounding.