Hoping that I can get some guidance here.
During two separate audits of telehealth visits performed during the pandemic, our auditors identified that providers are noting “no exam performed” in the charts. The examination is a key component when selecting the level of Evaluation and Management (E/M) code. Upon further review of telehealth guidelines issued during the pandemic, there is a lack of guidance on how to code these visits if an exam is listed as not being performed. These visits are being coded as 99201-99205 and 99212-99215 by the providers.
During the Coronavirus pandemic providers were encouraged to provide telehealth services whenever possible. These services should reasonably approximate an in-person visit. Coverage of telehealth services requires the same level of documentation, medical necessity, and coverage determinations as in-person visits. If the requirements are met, reimbursements are the same as reimbursement for in-person services.
Can anyone steer me in the right direction for guidance for documentation for the E&M portion of a telehealth visit?
During two separate audits of telehealth visits performed during the pandemic, our auditors identified that providers are noting “no exam performed” in the charts. The examination is a key component when selecting the level of Evaluation and Management (E/M) code. Upon further review of telehealth guidelines issued during the pandemic, there is a lack of guidance on how to code these visits if an exam is listed as not being performed. These visits are being coded as 99201-99205 and 99212-99215 by the providers.
During the Coronavirus pandemic providers were encouraged to provide telehealth services whenever possible. These services should reasonably approximate an in-person visit. Coverage of telehealth services requires the same level of documentation, medical necessity, and coverage determinations as in-person visits. If the requirements are met, reimbursements are the same as reimbursement for in-person services.
Can anyone steer me in the right direction for guidance for documentation for the E&M portion of a telehealth visit?