Telehealth consultation, emergency department or initial inpatient, typically 30
minutes communicating with the patient via telehealth
However, I have something from the Medicare Payment manual...10.3.2 that states:
"Practitioners taking a problem focused history, conducting a problem focused exam and engaging in medical decision making that is straightforward would bill HCPC code G0425."
This implies the expectation of an exam. We are debating how to credit our providers notes where they document exams. Clearly the hands on portion of the exam is being done by the provider at the referring or rural hospital. See below by way of example:
Head: Normocephalic. Macrocephalic: bruise behind R ear.
In C collar, no reported tenderness
Pulmonary/Chest: Effort normal and breath sounds normal. No accessory muscle usage. No respiratory distress. He exhibits tenderness.
Left chest wall tender to palpation
Obese, soft,, nontender
Genitourinary Comments: Normal male gen
Neurological: He is alert. He has normal strength. GCS eye subscore is 4. GCS verbal subscore is 5. GCS motor subscore is 6.
No abnormalities described
I can not find anything in writing that says you can give your provider credit for the exam done by the referring MD at the originating site, however that makes sense to me, since it is a telehealth service. Other coders feel that we can only give our provider credit for any exam element that they can visually examine, since obviously they can not physically palpate the chest or listen to breath sounds, etc .
How are you all leveling these types of visits, related to the exam. Or do any of you just make the provider document the time and go with the generic HCPCS description, ignoring the CMS definitions above?
Thanks for any help!!