Question Telehealth Well Woman Visit

msksmith

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Manvel, TX
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Hello coders! Can anyone please clarify the correct process for the indicating the initial diagnosis & CPT in a telehealth visit, and then the follow-up diagnosis & CPT when they present in person for the full exam?
One of the nurse practitioners noted that for a telehealth visits they put well women without exam diagnosis because they can’t perform exam via telehealth visit. The patient will then follow up in the office for a physical exam and then the provider would put well women with exam as the diagnosis. I understand for some coverages, that there can only be a dx of well women (with or without exam) a certain number of times a year.
Thank you in advanced!
 

ccditroia@gmail.com

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Marlton, NJ
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how soon will the patient follow up for an in person visit? if not within 24hrs of the call I would check with payor specific guidelines because there were so many exceptions made due to the pandemic

Christine DiTroia CPC
 

csperoni

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Selden
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If they are coming in anyway, why are you making them go through a telehealth visit as well? Am I missing something?
That's sort of my take on it, but I do know there are practices that are doing what they can to limit the amount of time a patient is present, or number of staff interacting.
Example: provider typically spends 5 minutes updating history, 5 minutes on exam, and 10 minutes counseling/discussing birth control options, etc.
The 5 minutes on history and 10 minutes counseling can be done via telehealth or telephone, so the patient and provider only need to be in the same room for 5 minutes vs 20 minutes.
If your practice is doing this, I would STRONGLY encourage the work other than exam to be done the same day. It makes it black and white from a coding perspective. My practice is not doing this (other than taking new patient history), so I have not thoroughly investigated the requirements if they are done different days.
 

ccditroia@gmail.com

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Marlton, NJ
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Hi Christine! Thanks so much for responding! The in person follow-up visit will be within 24hrs with the exam.
As per page 39 of the CPT book "......if the telephone service ends with the discussion to see the patient within 24hrs or next available urgent appt , the code is not reported; rather the encounter is considered part of the preservice work of the subsequent E/M service,....."

hope that helps

Christine DiTroia CPC
 
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