EM Coding Alert

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, so be very careful that the documentation supports the level of MDM your provider selects. Also, watch out if you are using total time of, say, 60 minutes for a minor problem. Payers will be scrutinizing the documentation for higher level of services after the emergency is over.

If your providers are reporting the 993XX codes, then they can state the exam was deferred, but make sure all of the other requirements are met. Also, keep in mind that since they have been paid for doing an exam, payers will not expect your provider to bill the patient separately for just a gyn exam once the emergency period is over. Your office should really be establishing a protocol for this prior to billing later on.

Smart: Also, you should be accessing the COVID-19 policies of your major payers — especially Medicaid as their documentation requirements may also include such things as: a notation in the medical record that indicates that the service was provided via telehealth, the technology used, and the physical location of the distant and the originating sites. Most requirements seem to include the CPT^® code for the service rendered via telehealth be recorded in the patient’s medical record. If you are billing the quick e-visits or virtual visits, the patient must also give verbal agreement to the service, but you better make sure that is verifiable.