Revenue Cycle Insider

Question: An established patient is seen by telehealth for follow-up of diabetes, hypertension, and chronic kidney disease. During the encounter, the patient reports worsening fatigue and several elevated home blood pressure readings. The provider reviews recent laboratory results, adjusts the antihypertensive regimen, and recommends close follow-up. The provider submitted the encounter as 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.), but the documentation is brief. What should the coder verify before reporting 99215?

Oregon Subscriber

Answer: Telehealth encounters follow the same office/outpatient E/M coding rules as in-person visits, so you’re on the right track in looking at the established patient visit codes.

Multiple chronic conditions and medication management without documented high-risk management or severe exacerbation/progression generally do not support 99215.

With that in mind, you should report 99215 only if the note supports high medical decision making (MDM) or 40-54 minutes of total physician or other qualified healthcare professional time on the date of the encounter.

To report 99215 with confidence, the provider’s documentation should show the problems actually addressed and why the provider’s management rose to a high level. Coders should not infer worsening status or severity unless the provider documents that trend specifically.

If you’re selecting a code based on time, make sure the total time the provider spent is stated in the patient’s record. Although this was a telehealth follow-up, you’ll follow the same office or other outpatient E/M rules used for an in-person visit. A brief virtual note may support 99215, but only if it clearly supports high MDM or the required time.

Based on the limited details provided, the documentation more likely supports moderate MDM; therefore, report 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.) unless the provider documents additional risk, severity, or data elements.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC