Does a Practitioner Need to Document Time for a Telehealth Visit?

Question: 

Does a practitioner need to document time for a telehealth visit? What if it is audio only?

Answer:

First: For a telehealth visit, always document if it is with video or audio only. Documenting “telehealth visit” or “telemedicine visit” doesn’t differentiate this.

Second: If you are using office visit codes (99202—99215), you can select based on time or medical decision making. But, some payers, think Medicare, require you to use phone codes (99441—99443) for audio only. CMS increased the fees for these codes to match established patient visit codes.

When reporting office visit codes, you don’t need time. When reporting phone codes, you do need time, because those codes are selected based on time. The complication is that the practitioner may not know which visits are being reviewed behind the scenes and translated to another type of visit.

My recommendation: for real-time, audio/visual telecommunications you are not required to document time, if using MDM to select the code.

For audio only, document time.

More telehealth coding resources