Documentation Requirements

Documentation Requirements

April 16, 2020

Question:
What are the documentation rules for telehealth visits?

Answer:
Medicare now says that the appropriate E/M code for the telehealth visit (real-time audio and video) may be chosen based on Medical Decision Making (existing guidelines – not the new 2021 guidelines) or total amount of time. This is good news for surgeons who oftentimes must choose a lower level E/M code because the Examination component is not met. Be sure to have good documentation of the MDM or time – whichever you use to choose the level of billed E/M code.

*This response is based on the best information available as of 04/16/20.

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