Who requested the visit: patient/family/nursing
Who consented to the visit being conducted via Telehealth
"Nursing is requesting a visit due to worsening cough. The patient consents to being seen virtually today."
Documentation must include where the patient is located and where the provider is located.
"Patient is currently at Oakbrook Nursing Facility. Provider is at private residence"
Documentation must include anyone who is assisting with the virtual visit
"CNA Ashley B. is present at the bedside and assisting with the exam"
Be sure to document in the HPI and /or A&P any records, diagnostics, labs, etc. that were reviewed and how.
"Recent labs were reviewed via facility EHR. Nursing sent recent CXR report via HIPAA compliant email"
Physical exam
- only document PE findings that were possible via video call.
- If you document findings that are not possible via video, the source of the information must be documented.
Determining level of service for telehealth:
1.complexity
amount and complexity of conditions managed amount and complexity of date risk
2time spent
99308 with modifier 95
Use of the normal place of service where the patient would typically be seen.
If you have a patient who lives in an assisted living facility, but is normally seen in the office, you will use POS 11-office
DO NOT USE POS 02-telehealth
Do not bill an E/M service code (99334-99337, 99307-99310, 99495-99496,) as a telehealth visit if real time video function was not used or able to be used.