Telehealth E/M services

nikki_coder

Networker
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Does anyone have verbiage from CMS on how you are to choose a level of service (99201 - 99205 & 99212 - 99215) when the providers are unable to do a hands on examination other than note the general appearance of the patient? Do you instead choose your level based mostly on the medical decision making involved?
 
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Coeur d'Alene, Idaho
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The 1995 and 1997 guidelines still apply for these services. Our providers have typically limited these services to established patients which makes it a little easier to reach your required elements for a level of service as only 2 of 3 areas are required to meet the level of service and our facility requires MDM to be one of the 3. I would imagine that if providers begin utilizing telehealth for new patients, they will likely only meet 99201 or maybe a 99202 depending on what they are able to realistically document for exam elements. Alternatively, the provider could also document their note using time as the basis for their selection of the level of service, making sure to include a statement of the total time spent face-to-face with the patient, that 50% or more of that time was devoted to counseling and/or coordination of care, and a summarization of the content of the counseling/coordination of care.
 
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