April 30, 2020

Question:
What documentation is needed to bill for a phone only visit besides time?

Answer:
There aren’t any specific rules about documenting telephone calls for covered telephone call services during the current public health emergency, but the general principles of documentation should be your guide. Remember that medical necessity should be documented, and you should include the following:

• Notation that patient consented to the consult held via telephone
• Names of all people present during a telemedicine consultation and their role
• Chief complaint or reason for telephone visit
• Relevant history, background, and/or results
• Assessment
• Plan and next steps
• Total time spent on medical discussion
  

*This response is based on the best information available as of 4/30/20.