Since the start of the COVID-19 Public Health Emergency (PHE) the term telehealth has been used as an umbrella term for any type of telemedicine visit. However, everyone should be familiar with the different types of virtual visits and what should be documented for each method. It seems the most popular virtual visits are audio only, and concurrent audio and video encounters. Each one has slight variations in documentation requirements. To accurately code these services, you should familiarize yourself with the difference between each service and the documentation requirements.
Telehealth Service
Conducted via concurrent audio and video (i.e., Zoom, Doxyme, FaceTime)
Documentation should include:
- Consent-It is best practice to note the patient consent for this visit, or that previous consent was obtained. Consent should be obtained, at minimum, yearly.
- Mode in which visit is conducted-A provider can simply state that “This visit is conducted via audio and video” or “This visit was conducted via Zoom via audio and video” or something similar.
- Duration/Time-The total time of the encounter needs to be noted. It is best practice to note the exact time spent, not just a time range for the associated E/M face-to-face visit CPT codes that the provider marks off on a template.
- Patient’s chief complaint, medically appropriate history, exam, and medical decision making with patient’s diagnosis and plan of care.
Examples of insufficient consent or time documentation:
“Consent obtained.”
This visit was conducted via telehealth.
New patient: Established patient:
__ 15-29 minutes __ 10-19 minutes
__ 30-44 minutes __ 20-29 minutes
__ 45-59 minutes _X_ 30-39 minutes
__ 60-74 minutes __ 40-54 minutes
Great examples of consent and time documentation:
“The patient provided verbal consent to the encounter occurring by concurrent audio & video via Zoom as opposed to in person in view of the COVID-19 pandemic.”
“I spent a total of 35 minutes during this encounter with the patient.
Telephone Visit
Conducted via audio only.
Documentation should include:
- Consent-It is best practice to note the patient consent for this visit, or that previous consent was obtained. Consent should be obtained yearly.
- Mode in which visit is conducted-A provider can simply state that “This visit is conducted via audio only” or “This visit is a telephone visit”.”
- Duration/Time-The total time of the encounter needs to be noted. It is best practice to note the exact time spent, not just a time range that is associated with the telephone encounter CPT codes that the provider marks off on a template.
- Patient’s chief complaint, medically appropriate history, exam, and medical decision making with patient’s diagnosis and plan of care.
Examples of insufficient consent or time documentation:
“Consent obtained.”
“Telehealth visit conducted via phone.” (this is not an appropriate statement because a true telehealth visit is conducted via concurrent audio & video, not just over the phone).
___ 5-10 minutes
__X_ 11-20 minutes
___ 21-30 minutes
Great examples of consent and time documentation:
“This encounter was initiated by the patient and conducted by phone. The patient provided verbal consent to the encounter occurring by phone as opposed to in person in view of the COVID-19 pandemic.”
“I spent a total of 15 minutes during this encounter.” Or “15 minutes spent.”
Comparison:
| Telehealth | Telephone | |
| Consent | “Patient consented to this telehealth visit.” Or “Consent previously obtained from patient for this telehealth visit.” | “Patient consented to this telephone visit.” Or “Consent previously obtained from patient for this telephone visit.” |
| Mode | “This visit is conducted via audio and video” or “This visit was conducted via Zoom via audio and video.” | “This visit is conducted via audio only” or “This visit is a telephone visit.” |
| Duration/Time | “I spent a total of 35 minutes during this encounter.” Or “35 minutes spent.”
|
“I spent a total of 15 minutes during this encounter.” Or “15 minutes spent.”
|
*The mode and the duration/time of the visit are required and should be documented for every visit.
