Introduction to Telehealth Coding

Clinical Issues and Solutions/Documentation Guidance

Susanne Talebian, CUA, CPC-I, CPC


Urol Nurs. 2020;40(4):195-200. 

In This Article

Telehealth Services and Locations That can be Rendered, and Eligible Patients

This expansion of telehealth services was intended to increase access to health care and reduce the spread of COVID-19. It is applicable for all COVID-19 and non-COVID-19 patients, according to professional judgment, and for medically necessary services and capable of being provided through telehealth under given circumstances. These services can be rendered in the private setting, private practice, clinical setting, and home.

The Centers for Medicare & Medicaid Services (CMS) and DHHS declaration allows issuers to modify plans to provide pre-deductible covered testing for COVID-19 for high-deductible/catastrophic plans. This PHE also reduces restrictions on providers, increases scope of practice, and allows crossing state lines to provide services according to the individual state board of medicine licensing. The DHHS and the Food and Drug Administration (FDA), under the "Enforcement Policy for Non-Invasive Remote Monitoring Devices Used to Support Patient Monitoring During the Coronavirus Disease 2019 (COVID-19) Public Health Emergency (Revised)" provide guidance on types of medical devices that can be utilized for remote physiologic monitoring (RPM) of patients in their homes. These include thermometer, ECG, pulse oximetry, non-invasive blood pressure, respiratory rate, breathing frequency, cardiac monitor, ECG software, and electronic stethoscopes, as well as other devices.

Before COVID-19, services restricted providers who can perform telehealth services, and locations were restricted. During COVID-19, the list of CPT and HCPCS codes included 80 expanded services, and patient cost-share could be waived. There are expanded lists of providers who can perform these services, and location restrictions have been lifted. These changes were retroactive to March 6, 2020, until end of PHE, or the location's restrictions are lifted for provider and patient; are paid at the same rate as regular, in-person visits; and supervision changes from direct to general supervision, allowing for more access to patient care. Among these services are emergency department visits, observation care, initial and follow-up hospital consultations and visits, nursing home care, domiciliary and rest home visits, and at-home visits. These home services may be rendered by physicians, nurse practitioners, physician assistants, nurse midwives, clinical registered nurse specialists (CRNAs), clinical psychologists, licensed clinical social workers, registered dietitians, or nutrition professionals according to state scope of practice, and in line with regulations of CPT guidelines and CMS regulations. On April 14, 2020, IFR2 legislation expanded to include physical therapists, occupational therapists, and speech language pathologists, and made this retroactive to March 1, 2020.

Office and other outpatient visits can now be rendered to new or established patients (codes 99201–99215). Since the physical examination cannot be performed, the recommendation from the DHHS is for providers to choose the appropriate level of service based on time or the medical decision-making component of the interaction. This includes the number of diagnoses and treatment options, amount and/or complexity of data ordered and/or reviewed, risk of complications, and/or morbidity/mortality.

The history component requirements were removed as well; providers may obtain pertinent positives or negatives regarding the history of present illness, and review of system, past family, and social history as deemed necessary based on the primary concern or complaint. A chief complaint is required because it is reason for the visit, as is required in some form by electronic medical record systems for the visit to be signed. CPT and CMS have a variance in the average time rendered for these services (Table 1).

To date, there is no precise guidance for medical record documentation of telehealth services; many facilities may develop their own wording, often with legal department input when possible (see Box 1 for an example).