Telehealth Grid

MCA Telehealth Team

December 3, 2020

Documentation:

  •  Patient initiated and consent (written or verbal)
  •  Same as any face-to-face patient encounter, with the addition of the following:
  •  A statement indicating the service was provided via telehealth:
  •  Patient location
  •  Provider location
  •  Names of all persons participating in the telehealth service and their role in the encounter
  •  For time-based services, include the clinical or physician time relative to the encounter

Document start and stop time or total time. 

NGS coding questions for E/M;

Question: Some E/M services require performance of 3/3 elements (history, examination and MDM). May these services be performed via telehealth?

Answer: Yes, these services may be performed via telehealth. History and MDM are readily accomplished via telehealth communication. Examination via telehealth is limited, but pertinent observations (e.g., as skin color, skin lesions/rashes, quality of respiration and evidence of wheezing or dyspnea, vital signs as reported by the patient) are feasible and may be counted toward an examination. The provider should note the limitation of the examination based on the telehealth context. Documentation requirements for E/M services (and all telehealth services) have not been changed by CMS. The medical record should include mention of the fact that the service is being performed via audio/visual telehealth technology.

Question: Can time-based E/M services be performed via telehealth?

Answer: Yes, a time-based E/M service, during which >50% of time is spent in counseling/ coordination of care, may be performed via telehealth.

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