I have visits with appointment type : “Telemedicine 10 minute”

Here , Do we need to use modifier with E & M codes over here depending on the type of appointment ? If yes Which ?I mean as per my knowledge, 95 modifier with CPT code for commercial insurance plans, while the GT modifier must be included for Medicare and Medicaid plans is used. Request to guide the importance and requirement of these modifiers and effect on payment.

Chief Complaint

None recorded.

Vitals

None recorded.

Allergies

Allergies not reviewed (last reviewed 12/13/2018)

Medications

Medications not reviewed (last reviewed 12/13/2018)

Flucelvax Quad 2018-2019 60 mcg (15 mcg x 4)/0.5 mL IM suspension

12/08/18 filled MEDCO

predniSONE 50 mg tablet

10/26/18 filled MEDCO

Vaccines

None recorded.

Problems

Reviewed Problems

Family History

Family History not reviewed (last reviewed 12/13/2018)

Social History

Social History not reviewed (last reviewed 12/13/2018)

Smoking Status: Never smoker

Surgical History

Surgical History not reviewed (last reviewed 12/13/2018)

Appendectomy – 08/2001

Past Medical History

Past Medical History not reviewed (last reviewed 12/13/2018)

HPI

Pt here for 2nd visit to discuss condition and develop a relationship. We discussed the above and future use of medical marijuana.

ROS

ROS as noted in the HPI

Physical Exam

Patient is a 25-year-old male.

Constitutional: General Appearance: healthy-appearing, well-nourished, and well-developed. Level of Distress: NAD. Ambulation: ambulating normally.

Psychiatric: Insight: good judgement. Mental Status: active and alert and normal mood. Orientation: to time, place, and person.

Head: Head: normocephalic and atraumatic.

Eyes: Lids and Conjunctivae: non-injected and no discharge.

Neck: Neck: supple and trachea midline.

Skin: Inspection and palpation: no rash, lesions, ulcer, induration, nodules, jaundice, or abnormal nevi and good turgor.

Assessment / Plan

Pt here for followup visit. We discussed patient’s future use of MMJ. We discussed the risks and benefits. Pt understands that we will certify patient, but the recommendation does not constitute a prescription for medical cannabis.

Pt here with below diagnosis – pt here for evaluation for their condition, evaluation of their medication use, and discussion for alternative treatments.

1. Multiple sclerosis

G35: Multiple sclerosis

Return to Office

None recorded.