Q&A: Documenting time for telehealth and telemedicine

Q: Should providers be documenting the time for all telehealth and telemedicine visits?

A: Documenting time is only critical when it’s a time-based code or you’re going to bill, for example, an evaluation and management (E/M) service based on time. Under the interim final rule, CMS is allowing for E/M services to be reported based on medical decision making, so you could argue that’s somewhat of an early adoption of the rules effective January 1, 2021.

What’s important about documentation is that for every encounter it must be documented that the patient consented to the telemedicine service. That’s a requirement for everything. So be sure that’s on all the notes.

The time documentation, particularly the start and stop time, is only relevant for those CPT® descriptions that require start and stop time to be documented. So, particularly for your therapies where you’re billing in 15 minutes and so on, that’s where it’s going to be really important.

Note: This question was answered by Joe Rivet, Esq., CCS-P, CPC, CPMA, CICA, CHRC, CHPC, CCEP, CAC, CACO, during the April 28 NAHRI Quarterly Conference Call. The answer was provided based on limited information and does not constitute legal advice.