JUN 03, 2020
Telehealth Billing Without Access to Patient Chart
Question: I have a doctor who performed an exam via video conference, however she was unable to access our EHR or the patients record. Since we are including the progress note in the chart, are we able to submit for the service?
Answer: Yes, the exam is billable. A progress note in the chart documenting the encounter and date of service is sufficient. However, since code level selection based on time includes only physician time spent on the date of service, time spent charting on a different date cannot be used to support a higher code level. Compare the code level supported by medical decision-making to that supported by time.
Visit Coding for telehealth for more information.