Documenting a Telehealth Exam on the Web

Eyefinity EHR enables you to document telehealth services much like you would a typical visit when a patient is in the office.

This topic addresses the Eyefinity EHR web app. For iPad app information, go to Documenting a Telehealth Exam on the iPad.

Documenting Visits Using the Built-in Video Telehealth Feature

Create a new visit and initiate the video telehealth call within the Eyefinity EHR web application. Document the exam as you normally would. Eyefinity EHR autocodes the appropriate 992xx code based on the exam elements you document and appends the 95 modifier. For more information, go to Conducting Video Telehealth Exams.

Documenting Visits Using other Telehealth Technology

Outside of your ordinary documentation, here are the key steps you'll need to take:

  • Setting the visit type to one of the telehealth options under Manage Visit Settings
  • Documenting the eye exam portion of a telehealth visit

  • Selecting the appropriate plan depending on the nature of your encounter with the patient and what billing code you want Eyefinity EHR to generate

    For information on the billing codes CMS recognizes for telehealth services, see Understanding Telehealth Codes.

For instructions on telehealth documentation from the iPad app, see Documenting a Telehealth Exam on the iPad.

Visit Type

You can configure the visit type as a telehealth encounter by managing the visit settings. For more information, see Managing Visit Settings and Adding Notes.

Eye Exam

Documenting the eye exam portion of a telehealth visit is done the same way regardless of what technology (i.e. video or telephone) was used to conduct the visit.

  1. Open a patient's visit.
  2. Go to the Ocular Exam Room.

  3. Click Perform Exam.

    The Select Exam Set window opens.

    The tabs across the top of the screen show various types of exam sets.

  4. Click the Telehealth tab.

  5. Select Telehealth Eye Exam.

    An abridged version of the usual eye exam screen appears. This abridged eye exam focuses only on areas typically assessed as a part of a telehealth visit. Unlike the standard Eye Exam set, no findings are indicated by default.

  6. Document your eye exam findings.

    For general instructions on documenting eye exam findings in Eyefinity EHR, see Recording Findings in the Eye Exam.

  7. Click Done with exam when you are finished.

    Your exam findings are saved. You can review what you recorded by scrolling down to the Progress Note at the bottom of the screen.

Plan

If you prefer to bill 994xx codes, select the appropriate plan in the Ocular Exam Room. The plan you select for your documentation depends on how the telehealth exam was conducted.

Documenting the telehealth plan is not required for the 992xx with 95 modifier.

  1. Open a patient's visit.
  2. Go to the Ocular Exam Room.
  3. Select a diagnosis.

  4. Under Plans, select Telephone E/M Service.

    The plan details window opens.

  5. Select the appropriate billing code from one of the following drop-down lists.

    • Physician or NP/PA Digital E/M Plan: 99421, 99422, 99423

    • Qualified Nonphysician/Physical Therapist Digital E/M Plan, for Medicare: G2061, G2062, G2063

  6. Leave Bill Visit as E-Visit? set to Yes if you want Eyefinity EHR to use the code you selected above for billing.

    If you're billing a 992xx code and want to generate a 95 modifier, set this to No.

  7. Enter the Cumulative time spent (minutes) with the patient.

  8. Review the Criteria for the telehealth visit and deselect a statement if it is not true.
  9. Document the On-line medium used.
  10. Document a Description of on-line interaction.
  11. Type any additional Comments as needed.

  12. Click Done when you are finished.

    The plan is saved, and the billing code you selected is applied to the visit, which you can review from the Billing section of the Visit Overview screen.

  1. Open a patient's visit.
  2. Go to the Ocular Exam Room.
  3. Select a diagnosis.

  4. Under Plans, select Telephone E/M Service / Virtual Check-in.

    The plan details window opens.

  5. Select the appropriate billing code from the Telephone E/M for Some Commercial Carriers drop-down menu: 99441, 99442, 99443.

  6. Leave Bill Visit as Telephone Encounter? set to Yes if you want Eyefinity EHR to use the code you selected above for billing.

    If you're billing a 992xx code and want to generate a 95 modifier, set this to No.

  7. Enter the Cumulative time spent (minutes) with the patient.

  8. Review the Criteria for the telehealth visit and deselect a statement if it is not true.
  9. Document the Technology used.
  10. Document a Description of interaction.
  11. Type any additional Comments as needed.

  12. Click Done when you are finished.

    The plan is saved, and the billing code you selected is applied to the visit, which you can review from the Billing section of the Visit Overview screen.

Additional Requirements

Depending on the code and insurance you're billing, you may be required to capture additional information as a part of your telehealth services. Information such as Place of Service for telehealth should be entered on the practice management side of the platform.

For instructions on billing, see the following topics: