What is the billing level for a telehealth visit for a patient with cough and sore throat?

Billing Level for Telehealth Visit: Cough and Sore Throat

Bill based on either total time spent or medical decision-making complexity, whichever yields the appropriate level—for a straightforward acute upper respiratory complaint like cough and sore throat, this will typically be 99212 (established patient) or 99202 (new patient) based on straightforward MDM, or 99213/99203 if low complexity MDM is documented. 1

Determining the Appropriate Code Level

For Established Patients

• 99212 requires either 10-19 minutes total time OR straightforward medical decision-making 1
• 99213 requires either 20-29 minutes total time OR low complexity medical decision-making 1
• A simple acute cough and sore throat presentation typically qualifies as straightforward MDM unless complications or diagnostic uncertainty exist 1

For New Patients

• 99202 requires either 15-29 minutes total time OR straightforward medical decision-making 1
• 99203 requires either 30-44 minutes total time OR low complexity medical decision-making 1

Medical Decision-Making Complexity Assessment

Straightforward MDM (Supports 99212/99202)

• Self-limited acute upper respiratory symptoms with clear viral etiology 2
• No significant comorbidities requiring consideration 2
• Minimal data review needed 1

Low Complexity MDM (Supports 99213/99203)

• If you document consideration of bacterial pharyngitis vs viral illness, review of symptom severity, assessment of need for testing (rapid strep), or consideration of complications, this elevates to low complexity 1
• Multiple symptom management options discussed (symptomatic treatment, antibiotics if indicated) 3

Critical Documentation Requirements for Telehealth

You must document these additional telehealth-specific elements beyond standard E/M documentation: 2

• Patient consent to telemedicine 2
• Method of telemedicine (secure 2-way interactive video connection or phone call) 2
• Patient location 2
• Provider location 2
• All clinical participants' roles and actions 2
• Other individuals present at the visit 2

Billing Mechanics

Code Selection Strategy

• Calculate both time-based and MDM-based levels, then bill whichever is supported by documentation and yields the appropriate code 1
• For audiovisual encounters, include appropriate Place of Service code and telehealth modifier (CPT modifier 95) 2
• For telephone-only visits, bill based on time using telephone visit codes 2

Time-Based Billing

• If using time, document total face-to-face time with the patient during the encounter 1
• Time includes pre-visit review, the encounter itself, and post-visit documentation on the date of service 1

Clinical Context Considerations

Appropriateness of Telehealth for This Complaint

• Acute illnesses like cough and sore throat may be less ideal for telemedicine compared to chronic stable conditions 2
• Physical examination limitations exist—telemedicine shows poor concordance with in-person examination for pharyngeal assessment, particularly for posterior structures 4
• However, telehealth has been successfully used for low-acuity respiratory complaints during COVID-19 with acceptable safety profiles 5

Common Pitfalls to Avoid

• Do not use outdated 2013 time thresholds—the 2021 guidelines significantly changed time requirements 1
• Do not bill standard office visit codes without appropriate telehealth modifiers and Place of Service codes 1, 6
• Ensure problems are actively addressed during the encounter, not merely listed in the chart 1
• Document why telehealth was appropriate despite physical examination limitations 2

Practical Billing Approach

For a typical straightforward cough/sore throat telehealth visit:

• Established patient: Bill 99212 if encounter is 10-19 minutes or demonstrates straightforward MDM 1
• New patient: Bill 99202 if encounter is 15-29 minutes or demonstrates straightforward MDM 1
• Upgrade to 99213 (established) or 99203 (new) only if you document low complexity MDM elements such as diagnostic uncertainty, data review, or moderate risk considerations 1