Documentation tips

Suggestions for documentation and billing

This is a high level overview of some best practices and considerations when it comes to both documentation and billing in relation to telehealth. The laws for each state and practice type may vary. This is also a rapidly evolving area of development so use this information only as a rough guide. Always follow the recommendations of your institution or practice.

Documentation
Billing

Documentation for a telehealth visit should be the same as for other visits with some modifications.

Ensure that each visit has the following details:

Provider Location
Patient Location
Established versus new patient
Was the Consult performed using video? Yes/No
Was verbal consent obtained?
Date of consent obtained?
Start time of appointment
End Time
Duration of the visit (needs to be at least 11 minutes for billing purposes)
3rd person or interpreter used? Yes/No

Parent Led Vitals

If parents have a scale ask them to get a weight of the child or baby.

If parents have a measuring tape: can measure height for child and head circumference (<24 months)

Special Considerations

Since the Video Visit will have a limited Physical Exam, the History section must support the Assessment & Plan.

Summary of Telehealth Billing Codes

A summary of codes that may help guide your billing is included here. Please check with your specific billing departments to verify these are the ones you should follow for your clinic.

In general you should use the appropriate CPT or ESPDT code plus a telehealth modifier code (plus any of the additional codes that are applicable to the service that was provided)

OUTPATIENT, NEW	CPT-4 CODE
New Patient, straightforward, 10 min	99201-95
New Patient, straightforward, 20 min	99202-05
New Patient, low complexity, 30 min	99203-05
New Patient, mod complexity, 45 min	99204-05
New Patient, high complexity, 60 min	99205-05

OUTPATIENT, ESTABLISHED	CPT-4 CODE
Established Patient, brief, 5 min	99211-95
Established Patient, straightforward, 10 min	99212-95
Established Patient, low complexity, 15 min	99213-95
Established Patient, mod complexity, 25 min	99214-95
Established Patient, high complexity, 40 min	99215-95

TELEPHONE VISITS, MD/DO	CPT-4 CODE
Phone evaluation and management, 5-10 mins	99441
Phone evaluation and management, 11-20 mins	99442
Phone evaluation and management, 21-30 mins	99443

TELEPHONE VISITS , RN/MA	CPT-4 CODE
Phone evaluation and management, 5-10 mins	98966
Phone evaluation and management, 11-20 mins	98967
Phone evaluation and management, 21-30 mins	98968

Well Visit, NEW PATIENT	CPT-4 CODE
Infant (younger than 1 year)	99381-95
Early childhood (age 1–4 years)	99382-95
Late childhood (age 5-11)	99383-95
Adolescent (Age 12-17)	99384-95
Older adolescent (18+)	99385-95

Well Visit, ESTABLISHED PATIENT	CPT-4 CODE
Infant (younger than 1 year)	99391-95
Early childhood (age 1–4 years)	99392-95
Late childhood (age 5-11)	99393-95
Adolescent (Age 12-17)	99394-95
Older adolescent (18+)	99395-95

FOLLOW UP, ESTABLISHED PATIENTS	CPT-4 CODE
Follow up to virtual well visit	99429-95 (Unlisted Preventive Medicine Service Code)

Disclaimer

These documentation and billing tips are just meant to be a general guide. You should look to your local institution or clinic policies for more specific guidance.

By: Maria Rivera MD

Last updated: July 2020

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