Report E/M and Signs and Symptoms, Too
Question: A patient’s medical chart says that the provider spent 20 minutes in a telehealth visit via the patient portal with a 5-year-old pediatric patient experiencing diarrhea for several days and his mother. The physician ordered an enteric polymerase chain reaction (PCR) panel for analysis, should the mother be able to collect a stool sample. How should I code this encounter? Alabama Subscriber Answer: Look to the relatively new telehealth-specific evaluation and management (E/M) CPT® codes to capture this type of encounter. E/M code 98005 (Synchronous audio-video visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.) could fit this situation. Of course, you should check with the payer directly and make sure you follow their policies on telehealth visit coding. Some payers might prefer that you report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.) with modifier 95 (Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system) appended. For diagnosis coding, look to ICD-10-CM code R19.7 (Diarrhea, unspecified) as the reason for the visit, as you do not mention the provider having the results of the enteric PCR panel. Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC
