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Initial Visit
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F/U medical Visit
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Employee Demo (Leave Remainder of Billing Blank)
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Telehealth Consent
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Telehealth using App
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Originating site:
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Originating site:
• • •
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Distant site:
• • •
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Time Started:
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Time ended:
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Code G2211
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Provider-managed condition
• • •
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Provider-managed condition (not on the list)
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F/U
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Problems Addressed
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Comments
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Time Based Coding
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MDM Based Coding
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Time Based Billing
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Time Spent (if under 70 min)
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Prolonged Visit (if= >70minutes)
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Prolonged Visit 70-84 min (PPO)
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Prolonged Visit 70-84 min (medicare)
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Prolonged Visit 85-99 min (PPO)
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Prolonged Visit 85-99 min (medicare)
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Prolonged Visit >100 min (PPO)
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Prolonged Visit >100 min (medicare)
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Activities
• • •
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Incident to me
• • •
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MDM Billing
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# Problems
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Data Reviewed
• • •
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Low Risk (lifestyle intervention only)
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Moderate Risk (medication, minor procedure, or socially complicated)
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High Risk (major surgery or hospitalization)
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99212 (Problems=2, Data=0, Risk=low)
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99213 (Problems=3,Data =1. Risk=low)
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99214(Problems =4, Data =1.5, Risk=Moderate)
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99215 (Problems =5, Data = 4, Risk =High)
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Initial
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Preventive Exam (In-Person Only. PPO only)
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Telehealth Initial
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Initial with Preventive
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Patient's BMI and Category
• • •
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18-39 age
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40-64 age
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>65 age
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Time Based EM W P
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MDM Intial EM w P
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Time based Billing
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15–29 E/M
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30–44 E/M
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45–59 E/M
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60–74 E/M
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MDM based Billing
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# Problems
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Data Reviewed
• • •
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Low Risk (lifestyle intervention only)
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Moderate Risk (medication, minor procedure, or socially complicated)
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High Risk (major surgery or hospitalization)
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99202 (Problems=2, Data=0, Risk=low)
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99203 (Problems=3,Data =1. Risk=low)
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99204 (Problems =4, Data =1.5, Risk=Moderate)
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99205 (Problems =5, Data = 4, Risk =High)
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TIme Based Intial w/o Preventive
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MDM initial w/o preventive
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Time based Billing
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15–29 E/M
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30–44 E/M
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45–59 E/M
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60–74 E/M
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MDM based Billing
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# Problems
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Data Reviewed
• • •
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Low Risk (lifestyle intervention only)
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Moderate Risk (medication, minor procedure, or socially complicated)
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High Risk (major surgery or hospitalization)
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99202 (Problems=2, Data=0, Risk=low)
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99203 (Problems=3,Data =1. Risk=low)
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99204 (Problems =4, Data =1.5, Risk=Moderate)
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99205 (Problems =5, Data = 4, Risk =High)
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EM Problems
• • •
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Time Activities
• • •
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Incident to me
• • •
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Time Activities
• • •
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Incident to me
• • •
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MIPS
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MIPS Documentation
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Endocrine / Metabolic
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Diabetes: HbA1c
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HbA1c > 9.0%
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HbA1c not documented
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HbA1c < 7.0%
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HbA1c 7.0%–7.9%
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HbA1c 8.0%–9.0%
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Diabetes: Eye Exam
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Eye exam performed (current year)
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Negative retinal exam in prior year
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Eye exam not performed, documented reason
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Diabetes: Medical Attn for Nephropathy
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Positive microalbuminuria test
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ACE/ARB therapy documented
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Negative microalbuminuria test
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Nephrologist care, dialysis, or transplant
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Patient on treatment or being managed for nephropathy
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BMI Screening and Follow-Up
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BMI normal, no follow-up needed
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BMI high, follow-up documented
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BMI low, follow-up documented
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BMI not documented, no reason given
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BMI not documented due to medical reason or patient refusal
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BMI not normal, no follow-up, valid reason documented
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Cardiology / Cardiometabolic Care
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Controlling High Blood Pressure
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No BP documented
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BP <140/90
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SBP <140, DBP ≥90
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SBP ≥140, DBP <90
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SBP ≥140, DBP ≥90
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Screening for High Blood Pressure + Follow-Up
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Normal BP, no follow-up needed
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Elevated BP, follow-up documented
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Elevated BP, no follow-up documented
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No BP documented
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Not screened, documented reason
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Statin Therapy for Cardiovascular Disease
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Statin prescribed
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Not on statin therapy w/ no documented medical reason
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Documented clinical rationale for not prescribing
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Antiplatelet Therapy for CAD
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On antiplatelet therapy
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Aspirin or clopidogrel prescribed or currently being taken
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Not on antiplatelet therapy due to Medical reason
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Declined antiplatelet therapy
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Antiplatelet therapy Not prescribed, no reason
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Beta-Blocker Therapy for Heart Failure (LVEF < 40%)
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Beta-blocker therapy prescribed / Patient already taking
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Beta-blocker therapy not prescribed, documented medical/patient reason
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Beta-blocker therapy not prescribed w/o documented reason
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CAD: ACE Inhibitor or ARB Therapy (Diabetes or LVEF ≤ 40%)
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ACE/ARB prescribed/taken
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Contraindication documented
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Not prescribed w/o reason
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Anticoagulation for Atrial Fibrillation
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On anticoagulation therapy
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Contraindication documented
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High-risk score but no therapy prescribed
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Behavioral Health / Cognitive Disorders
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Depression Screening
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Depression negative, no follow-up needed
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Depression positive, follow-up documented
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Screening not done, no reason given
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Screening not done, patient/medical reason
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Depression positive, no follow-up documented
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Initiation, Review, and/or Update to Suicide Safety Plan
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20-minute safety planning intervention
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Elder Maltreatment Screening
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Positive screen + follow-up plan
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Negative screen, no follow-up needed
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Not eligible (refused or emergent)
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No documentation
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Positive screen, no follow-up
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Dementia / Cognitive Assessments
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Dementia: Cognitive Assessment
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Cognitive assessment performed and results reviewed
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Not performed; medical reason documented
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Not performed; patient reason documented
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Not performed; no reason documented
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Dementia: Functional Status Assessment
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Functional assessment performed and documented
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Not performed; medical reason documented
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Not performed; patient reason
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Not performed; no reason
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Preventive / Primary Care
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Influenza Immunization
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Vaccine administered or previously received
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Not received
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Pneumococcal Vaccination
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Vaccine administered
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Not administered, Documented medical reason
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Not administered without reason
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Tobacco Use Screening & Cessation
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Smoker screened + cessation done
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Smoker screened, no cessation done
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Non-smoker screened
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Not screened
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Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling
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Screening
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Counseling
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Documentation of Current Medications in the Medical Record
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Medication list documented
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Medication list not documented
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Sleep Disorders
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Sleep Apnea: Severity Assessment at Initial Diagnosis
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AHI/RDI/REI documented
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Reason for no assessment documented
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No assessment or reason
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Sleep Apnea: Assessment of Adherence to Obstructive Sleep Apnea (OSA) Therapy
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Adherence assessed (objective data or verified self-report)
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Documented reason adherence not assessed (e.g., therapy not yet started, no device data, patient declination)
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Adherence not assessed, reason not documented
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Falls & Geriatric Safety
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Falls
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Falls plan of care documented
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Patient not ambulatory
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Falls plan not documented
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Risk assessed
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Musculoskeletal Functional Status
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Functional Status Change for Patients with Knee Impairments
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Not Improved
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Improved
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Functional Status Change for Patients with Hip Impairments
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Not Improved
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Improved
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Functional Status Change for Patients with Lower Leg, Foot or Ankle Impairments
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Not Improved
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Improved
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Functional Status Change for Patients with Low Back Impairments
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Not Improved
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Improved
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Functional Status Change for Patients with Shoulder Impairments
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Not Improved
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Improved
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Functional Status Change for Patients with Elbow, Wrist or Hand Impairments
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Not Improved
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Improved
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Imaging / Surveillance
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Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients
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Recommended follow-up imaging
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Medical reason explained
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No follow-up recommended
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