When coding for Medicare telehealth visits, you can use either medical decisionmaking (MDM) or time as the basis for your selection of office/outpatient evaluation and management (E&M) levels of service, the Centers for Medicare & Medicaid Services (CMS) has clarified.
In an interim final rule effective May 8, CMS defined time as “all of the time associated with the E/M on the day of the encounter.” The definition of MDM remains unchanged (see below).
TMA’s practice management consultants recommend the following for documenting telehealth E&M services:
Time: Although CMS did not provide specific guidance on how to document time, at a minimum, document your time using “typical” times associated with the Current Procedural Terminology (CPT) E&M codes, as found in the current Medicare Physician Fee Schedule.
CPT Code Minutes
History and exam: The interim rule removes standard requirements regarding documentation of history and/or exam; however, document what is necessary to ensure quality and continuity of care, CMS said. Medical necessity remains the overarching requirement of the visit.
CMS defines medical decisionmaking as follows: Refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by: the number of management options that must be considered; the amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed; and the risk of significant complications.
For further clarification on E&M coding for time and medical decisionmaking during COVID-19, listen to the podcast below featuring TMA Practice Consulting Associate Carra Benson.
Major E&M Changes Are Coming in 2021
Watch for an upcoming webinar in the TMA Education Center presented by TMA Practice Consulting.
For information about Medicare telehealth during COVID-19, see Medicare Telehealth Frequently Asked Questions. See also the Texas Medical Association’s latest telemedicine tools and information.
You also can find the latest news, resources, and government guidance on the coronavirus outbreak by visiting TMA’s COVID-19 Resource Center regularly.