TELEHEALTH DOCUMENTATION GUIDE
1. General Issues:
a. This document is to briefly guide you
through proper documentation and coding for telehealth visits. It isn’t intended to teach coding basics,
especially with regards to Medical Decision Making.
b. Accurate documentation is just as
important for telehealth visits.
c. Telehealth visits do NOT need to be
recorded and saved.
d. For established patients, we still
need 2 out of 3 (History, Physical, MDM) to determine e/m coding level.
e. The accepted codes are only the e/m
codes. You cannot bill for a well visit,
high risk counseling (99401), weekend or holiday codes.
f. If you do a telehealth visit and then
need the patient to come briefly to the office for a procedure (such as a strep
or flu test) without an in office visit your biller will need to bill the
telehealth e/m visit as usual. For the
procedure, your biller will need to manually change the location of the
procedure to in office as opposed to telehealth.
g. You CAN BILL BY TIME and the same
rules apply. 99213 (13 minutes where at
least 50% of the time was counseling and coordination of care). 99214 (21 minutes where at least 50% of the
time was counseling and coordination of care).
99215 (33 minutes where at least 50% of the time was counseling and
coordination of care). You MUST DOCUMENT
time in your note by clicking the time button in our EMR or using the time
quick text.
h. If you are not billing the visit by
time, read below.
2. History Documentation:
a. The history requirements are no
different as for in-office visits.
b. Some reminders: Document allergies, medications, HPI with
pertinent ROS, Pertinent PMH, Family and Social history.
c. I personally am documenting in my
first line on the HPI that this is a telehealth visit, though I haven’t found
anything saying that is a requirement.
3. Physical Exams:
a. Though Physical Exam is much more
limited, we can perform and document a lot more than we currently are
doing. Remember, as with in-office
visits, we should be performing and documenting the pertinent and appropriate
physical exam for that specific visit issue.
(documenting tanner staging for sore throat and using that to increase
your physical exam level would be inappropriate)
b. Here are system by system tidbits
that you could use for documentation, if pertinent and applicable:
i.
Vitals: Home
Temperature, Home Weight
ii.
General: Appearance-
Sick/Not Sick, Pale, Tired, Sleeping, etc.
iii.
Skin: No
Rash/Rash described as follows:
iv.
Head: As
per parent anterior fontanelle is flat, Atraumatic
v.
Neck: FROM,
no stiffness, no tenderness when parent palpates lymph nodes, no obvious
masses
vi.
Eyes: (no)
discharge, (no) conjunctival injection, EOMI, (no) eyelid edema
vii.
Nose: Clear/purulent
rhinorrhea, nasal flaring
viii.
Ears: no
drainage, nontender when parent presses on ear canal
ix.
Mouth: (no)
pharyngeal erythema/exudates, palate intact, moist mucus membranes
x.
Chest: No
pin-point tenderness when parent presses on sternum, normal respiratory effort,
no splinting, (no) intercostal, subcostal retractions, no auditory stridor or
wheezing
xi.
CV: No
cyanosis, normal capillary refill
xii.
Abdomen: Able
to jump up and down without severe pain, (non-)tender exam when parent palpates
abdominal quadrants, (no) rebound, no distension
xiii.
Back: No
curvature noted
xiv.
Neuro: Alert,
responsive, normal gait, negative rhomberg, normal
strength
xv.
GU: (no)
vaginitis, discharge, erythema, no apparent hernia seen, (no) tenderness when
parent palpates testicles
xvi.
Psych: Normal
affect and mentation
4. Medical Decision Making:
a. The rules for MDM are the same as
they are for in-office visits. You need
2 out of 3 regarding Diagnosis, Quantity of Data Reviewed, Relative Risk to the
Patient.
b. Diagnoses: New Problem with no work
up, New Problem with work up, will get you the diagnosis points for a 99214 and
a 99215 respectively, just like an in-office visit. Established problem worsening gets you the
points for a 99213.
c. Quantity of Data: This might be harder to get to higher levels
of service. However, remember if you are
ordering blood work or x-rays, if you are sending them into the office for flu
or a strep test, those data points count just as they would in an in-office
visit.
d. Risk: A couple of comments with
regards to risk. The fact that your exam
is “limited” in certain areas, your risk in increased. Meaning, you aren’t putting YOUR hands on the
patients belly, so though you believe based on your
video observations that the belly isn’t surgical, you still need to keep that
in your differential and your discussion with the family. You should document that increased risk in
your note. Also, as we mentioned in
previous communications, the COVID-19 pandemic has increased the risk for
practically most fevers, coughs, even now diarrhea, eye discharge and inability
to taste or smell. If you document these
concerns in your notes, that will justify the increased level of risk.
5. Quick Texts:
.covid Because of the current pandemic, and
based on the patients symptoms and/or risk factors, will send out testing to
the lab for COVID-19. Patient instructed
to remain in self-quarantine until the results are received. If positive, will notify the Department of
Health.
.covidnotest Discussed with parent that the signs, symptoms and exam
are consistent with a viral infection.
In the differential is the possibility of COVID-19. Given lack of high risk
factors for this patient and for direct family members we will not test for
COVID-19. Proper handwashing and other
infection control discussed. Tylenol,
and hydration discussed. Call if
symptoms worsen. Self-quarantine until
no fever for 3-5 days.
.19phone Counseled on COVID-19 Pandemic. Specifically counseled on risk factors
for exposure and symptoms. Counseled on parameters for testing and
self-quarantine, as needed. Also
counseled on proper hygiene including hand washing and social
distancing. Monitor for fever, congestion, cough and/or shortness of
breath. Call back if further questions or need for telemedicine or in person
visit.
.covidremote
COVID crisis does not allow for a safe in person visit and therefore in
order to meet the needs of patient, the visit is being conducted remotely. All efforts have been made so that medical
advice given is the best possible under pandemic conditions.
6. HIPAA Policy Changes during COVID-19
The current pandemic has dramatically increased the need for
Telehealth. Fortunately, Allied has access to the
Anytime Pediatrics platform which is now live in all divisions.
There may be situations, where Anytime Pediatrics does not meet
the medical need. While HIPAA rules have been relaxed, violations may
still be levied. It is very important that we practice compliantly as much as
possible. Allied has set up Zoom access for specific types of telehealth
visits such as lactation (where doctor, patient and LC may need to be present
from different locations.) Please contact IT support if you have that need.
In addition, if you need to connect with a patient at a time when Anytime
is not reasonably available (the middle of the night,) you may ONLY use
Zoom.
The Office for Civil Rights (OCR) specified that Facebook
Live, Twitch, TikTok or other public facing video
tools should NOT be used for telehealth. OCR also states that
“healthcare providers should notify patients that such third-party apps pose
privacy risks” and “providers should enable all available encryption and
privacy modes when using such applications”.
You do NOT need to record visits on any platform. You DO
need to document the visit in the EMR. You need to write a proper note
using the telehealth template including a history, limited physical exam and an
assessment/plan. Using the telehealth template will make sure that your
E/M visit is billed with the correct telehealth modifier.