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Posted By Mary Peabody on 04-21-2020, 21:53:33 in Ob-Gyn
Hello Melanie,

Due to the COV-ID 19, our providers are performing mostly tele-health video visits. Is the documentation requirement the same for performing an in patient visit, especialty with the physical examination elements? If the patient is new or a GYN preventive visit is performed, is the physical examination components the same as it would be for an in person visit. many of the providers are documenting physical exam deferred due to the virsus for an annual check up.
Comments (2)
Posted By Melanie Witt on 04-22-2020, 13:22:31
And it also goes without saying that you should be accessing the COVID 19 policies of your major payers, especially Medicaid as their documentation requirements may also include such things as: a notation in the medical record that indicates that the service was provided via telehealth, the technology used, and the physical location of the distant and the originating sites. And most requirements seems to also include that the CPT code for the service rendered via telehealth be recorded in the patient’s medical record. If you are billing the quick e-visits or virtual visits, the patient must also give verbal agreement to the service, but you better make sure that is verifiable.
Posted By Melanie Witt on 04-22-2020, 13:04:43
For an E/M telehealth service you will base the documentation on total time or on MDM. The requirements for MDM have not changed so be very careful that the documentation supports the level of MDM your provider selects. Also watch out if you are using total time of say 60 minutes for a minor problem. Payers will be scutinizing the documentation for higher level of services after the emergency is over. If your providers are reporting the 993xx codes then they can state the exam was deferred, but made sure all of the other requirments are met. Also keep in mind that since they have been paid for doing an exam, I would not expect them to bill the patient separately for just a gyn exam once the emergency period is over. Your office should really be establishing a protocol for this prior to billing later on.
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