Wiki Is telehealth billable without patient present?

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andreareeder

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We have a number of providers asking if the patient must be present during a telehealth visit, and I am struggling to find a definitive answer.
One example would be a parent sets up a telehealth visit with pediatric specialist to ask questions regarding care of baby/child... does the baby/child have to be present on the call? What if the baby is napping, or the child is at school?
Another example would be adult children of an elderly patient. If there is a telehealth visit with the family caregiver, does the elderly patient need to be present on the visit?

I appreciate any feedback and reliable resources cited.
 
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Hi there,

The requirements for an E/M visit are the same whether they occur in-person or via telehealth. The doctor wouldn't bill a visit if the parent or adult child came to the practice without the patient, therefore they would not bill for the telehealth encounter without the patient.

There are ways to count conversations toward an office visit as explained in the E/M guidelines, but they have to be related to a patient encounter.
 
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jkyles@decisionhealth.com said:
Hi there,

The requirements for an E/M visit are the same whether they occur in-person or via telehealth. The doctor wouldn't bill a visit if the parent or adult child came to the practice without the patient, therefore they would not bill for the telehealth encounter without the patient.

There are ways to count conversations toward an office visit as explained in the E/M guidelines, but they have to be related to a patient encounter.
Click to expand...
That was my thought as well, but then I found this statement from the AMA, which makes it sound like a time-based E/M can be conducted with family or caregiver. Thoughts?

1651254793221.png
 
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andreareeder said:
That was my thought as well, but then I found this statement from the AMA, which makes it sound like a time-based E/M can be conducted with family or caregiver. Thoughts?

View attachment 5874
Click to expand...
The counseling/coordination of care concept doesn't apply to office visits. Office visits reported based on time require a face-to-face encounter with the patient, but you can include relevant conversations with family members if the conversation happens on the same day as the encounter.
 
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Good question, comes up a lot. In the office/outpatient setting the patient (sometimes, depending on payer) might have to be present because it requires face-to-face (patient & provider face-to-face). It depends on the payer and CPT you are trying to report. It also can depend on the year and whether there were flexibilities/relaxed rules added during Covid by particular payers regarding telehealth (or not). Some may allow it, some may not. Generally, reporting office/outpatient via telehealth requires the same face-to-face with patient as if performed in office. However, 2021 AMA CPT office/outpatient time definition says Physician/other QHP includes the following activities, when performed: counseling and educating the patient/family/caregiver.

See Medicare Claims Processing Manual Chapter 12, C. Selection of Level of Evaluation and Management Service Based On Duration of Coordination of Care and/or Counseling, "In the office and other outpatient setting, counseling and/or coordination of care must be provided in the presence of the patient...": https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

One thing to point out is per CPT, Non-Face-to-Face, Telephone Services (for established patients, no video, initiated by patient, guardian or parent) (99441-99443) can be reported for patient, parent or guardian discussion. You have to read the specific rules regarding related E/M within 7 days, etc. though. And, you have to find out if the specific payer even covers it. https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf

Medicaid per state may have different guidance on this too.

Telehealth reference: https://www.karenzupko.com/KZA-telehealth-solution-center
This is a good, general telehealth article although from 2020 https://journaloei.scholasticahq.co...-person-documentation-the-same-only-different

Good 2019 article that explains: https://www.medscape.com/viewarticle/916023?reg=1

I would also state if your provider is going to do it, they better have really great documentation because telehealth services are huge audit target now by all payers. See OIG workplan & telehealth:
 
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Hello Andreareader:)
The folks above have told you correct data. We must note in the OP setting that the provider must ensure correct patient and DOB, address, Etc written on top of their notations and the pt. agreed to telehealth service. Then provider must say talk to pt. on phone or online with telehealth for so many minutes; add to documentation for the day. All the same data stands for ROS, HPI, nature of compliant, or follow up for certain illness, check medications, reorder prescriptions and ending with assessment or dx list. Also sometimes they do amendments on end of note. You can use eva mgnt codes of 99203-99215 with proper documentation but add modifier 95 or 93 with it. Those codes are for MD, DO, NP and PA. Also nurses and qualified technicians can use CPT 99211 or 98966 series for calling patient to check up on them Etc. The CPT series of phone or telemedicine health are 99441-99443 (for MD, DO, MP and PA) and 98966 to 98968 for LPC social workers and qualified techs depending on documentation can use the Eva mgmt codes but must add modifier 95 video and modifier 93 phone.
I hope this data helps you.
Lady T:)
 
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