Davidson, James

» In documenting a patient encounter, the orthopaedic evaluation consists of 3 key components: “History,” “Physical Examination,” and “Medical Decision-Making.” » The level of service coded must be supported by the complexity of the problem, the care provided, and the documentation of the encounter. » Determining whether the patient is new or established is the first step in the evaluation and management (E/M) process and relies on same-practice/same-specialty rules. » Careful attention must be paid to documentation and coding to allow for appropriate care of the patient and efficient use of the orthopaedist’s time. The available step-by-step guidelines include all necessary criteria to accomplish this. » Continue to monitor for the U.S. Centers for Medicare & Medicaid Services (CMS) changes to stay up-to-date on changes in the guidelines.

➢ The coronavirus disease 2019 (COVID-19) crisis has disrupted health care in the United States and globally, and the ability to treat patients as we did in the prepandemic environment has changed. The safety of patients and providers, the avoidance of unnecessary exposure, and the cancellation of elective procedures have prompted the use of telemedicine. In addition, many large institutions are without a functioning videoconferencing platform and the use of telephone visits has become essential. ➢ Several important changes have been made by the Centers for Medicare & Medicaid Services to facilitate ease of access to telemedicine during the COVID-19 pandemic, including alternate place of service codes, visit time associated with evaluation and management services, and new Current Procedural Terminology codes for virtual visits with new patients. ➢ Although telemedicine visits do not allow for a hands-on physical examination, it is prudent for the medical provider to understand and learn the breadth of examination that may take place through an audio and video (when possible)-enabled virtual visit.