Wiki Tele Visit coded 99215?

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veloso

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Hi,
Needs help for Tele Visit coded 99215 for 9/30 (last visits on 9/2 billed 99213/95 and 9/16 billed 99214/95) because as per provider; She spent a long time coordinating care and speaking with the patient with total time 45 minutes with at least 50 percent spent counseling/ coordinating care, HPI; follow-up for suboxone med management follow-up. (Fyi start and stop time not noted in PN)


Please anyone!

Thank you!
IM
 
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Start/stop times are generally not required unless the carrier has a policy stating so. If the provider spent 45 minutes total on the date of the audio/video visit (and this is documented in the note), then 99215 seems appropriate.
Don't forget as of 1/1/21 for outpatient, time is total time spent by the provider on the date of the encounter and is not required to be >50% counseling/coordinating care.
 
Christine, Thanks a lot for the clarification highly appreciated!
Have a Happy Holidays with Your Family and Loved Ones!
And to Everyone, Enjoy and God Bless Us All!!!
 
I would add that the statement above is really vague and non-specific. Documenting things like, "I spent a long time coordinating care and speaking with the patient." but not actually detaling what was discussed and coordinated is not a good documentation practice. The provider should be specific and detalied as to what was done during the visit, what was discussed, and anything else such as reviewing tests, labs, referrals, etc.

Example: A total of X minutes was spent on this visit reviewing previous notes, counseling the patient on _______ , ordering tests (______), adjusting meds ______, and... etc etc.

Vague statements like "a long time", "lengthy visit", and "talking with patient" are triggers for auditors. Especially when talking about telehealth and high level E/M.

 
Yes, definitely agree with @amyjph that the note should contain an appropriate level of detail. I was assuming the original post simply extrapolated what was documented in the note with sufficient detail. Those are some excellent resources provided if that was not the case.
 
Fyi, PN notes provided detailed discussion on patient's status, treatment plans, etc. only the 'total time' spent was not documented.

Thank you All for the response!
 
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