Wiki Telehealth documentation

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taly

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Hello- one of my doctor's is questioning the documentation for his video visits with patients, we are a specialist office seeing patients with audio/video connections. Is the time documentation required? I know for telephone visits it is, but for the video, is time required in the dictation/report? Any help is greatly appreciated.
 
For telehealth E/M, time is not required. However, it is often helpful as you cannot really perform an exam via video. I am instructing my providers to always document the time since clearly > 50% is spent counseling co-ordination of care. I have heard that in the most recent changes, CMS is now permitting the 2021 E/M coding changes for these services, allowing MDM or total time (even if not > 50% counseling/coordination of care). I have not heard of any private carrier following this lead. For the time being, I am still coding all telehealth E/M by hx/exam/MDM or time.
 
I guess it may depend on the code set you're using. Obviously, the 9942x codes would require documentation of the cumulative time spent with the patient. However, I would also agree with @csperoni that it's a good idea to document the time spent on the telemedicine visit for the E/M codes. I've also seen that you should document that the patient gave permission for the telemedicine visit to be billed to their insurance and that you document the video platform you use, especially since non HIPAA compliant platforms, such as Skype and FaceTime, are currently OK to use.
 
We're asking our providers to document time for telehealth visits. I found a helpful guide from the AMA with coding examples for both COVID and non-COVID visits. Hope you all find it helpful, too.
 

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  • Special coding advice during COVID-19 public health emergency.pdf
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Does start and stop time need to be documented or just total time documented. We are also having Providers that do not want to provide time and are asking for proof that that is a requirement. Thanks!
 
Linda77 said:
Does start and stop time need to be documented or just total time documented. We are also having Providers that do not want to provide time and are asking for proof that that is a requirement. Thanks!
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All of the codes approved for telemedicine use have the time element described in their definitions. I'm sure that just recording the total time involved would be fine but I'd actually record the start and end clock times to be thorough. I know that OIG said it would be very lenient in any audit which included these visits done during the emergency period, but I'd want to dot all the I's i could to be safe.

Besides, how long does it actually take to record the times? Your docs can't be that busy right now to make that a burden.

Tom Cheezum, OD, CPC, COPC
 
I would say it depends on your carrier. In the updated CMS policy regarding telehealth, you may code based on time or MDM. Neither takes precedent.
I still have not heard of any private carrier adopting this same policy. So if the private carrier requires 2 of 3 on hx/exam/MDM OR time for established, and you only have MDM, then you must bill on time.
Just as a note - the updated CMS policy with the option to code by MDM only applies to telehealth, not in person services (until 2021 when the new rules take effect).
 
daedolos said:
Do you have a payor link on that? Also, I've heard that for inpatient or SNF, the required modifier is 95.

Peace
@_*
Thanks in advance.
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NGS Medicare advised on their FAQs:
When performing a telephone service only, do we append the 95 modifier? And, what place of service do we use?
Answer: Bill the place of service code relevant to where the provider was when performing the telephone service. A telephone service does not require the 95 modifier because it is not considered telehealth, where an audio/video platform was used. (Added 4/29/2020)
It's question 3 under Modifiers heading near the end.
That is the Medicare guidance. If you are asking about commercial payors, each payor could set their own policy, in which you would have to defer to that payor's policy.
 
Question: Can you include the nurses time getting the history before the physician does his speaks with the patient on the codes 99441-99443
 
csperoni said:
NGS Medicare advised on their FAQs:
When performing a telephone service only, do we append the 95 modifier? And, what place of service do we use?
Answer: Bill the place of service code relevant to where the provider was when performing the telephone service. A telephone service does not require the 95 modifier because it is not considered telehealth, where an audio/video platform was used. (Added 4/29/2020)
It's question 3 under Modifiers heading near the end.
That is the Medicare guidance. If you are asking about commercial payors, each payor could set their own policy, in which you would have to defer to that payor's policy.
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Just for curiosity sake, why would G2012 require the 95 modifier when it is also audio only?

Peace
?_?
 
daedolos said:
Just for curiosity sake, why would G2012 require the 95 modifier when it is also audio only?

Peace
?_?
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I don't think G2012 requires -95. It is not a telehealth code. Where did you see to put -95 on G2012?
 
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