tci E/M Coding Alert - 2020 Issue Q2

Reader Question: Examine Your Documentation for Telehealth Visits

Question: Due to the COVID-19 pandemic, our providers are performing mostly telehealth video visits. Is the documen­tation requirement the same for performing an in-patient visit, especially with the physical examination elements? If the provider performs a preventive visit, are the physical examination components the same as it would be for an in person visit? Many of our providers are documenting “physical exam deferred due to the virus” for an annual checkup. Nevada Subscriber Answer: For an E/M telehealth service, you will base the documentation on total time or on MDM. The requirements for MDM have not changed...

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