Orthopaedic Documentation and Coding Primer for Telemedicine and Electronic Patient Communication for the COVID-19 Pandemic

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.