Documentation and Billing Flashcards
7 cards from real CTP practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Documentation and Billing flashcards as text
Which modifier is appended to a CPT code to indicate a telehealth service was provided via audio-visual technology?
Answer: Modifier 95
Modifier 95 indicates synchronous telemedicine services rendered via real-time interactive audio and video telecommunications.
A telehealth provider sees a patient for the first time via video. What level of documentation is required compared to an in-person new patient visit?
Answer: The same history, exam, and medical decision-making standards apply
Documentation requirements for telehealth new patient visits mirror those of in-person visits, including history, exam elements performed, and medical decision-making.
Which element MUST be documented in every telehealth encounter note to support billing?
Answer: Confirmation that the patient provided verbal or written consent for telehealth
Documentation must confirm patient consent to the telehealth visit, as consent is a billing requirement under CMS and most state regulations.
Under Medicare rules, what is the role of the 'originating site' in telehealth billing?
Answer: It is the patient's physical location during the telehealth visit
The originating site is where the patient is located during the telehealth encounter, and it may be eligible for a facility fee under Medicare rules.
A patient calls in for a phone-only visit and does not have video capability. Which CPT codes are most appropriate for a 15-minute telephone E/M service?
Answer: 99441–99443
CPT codes 99441–99443 describe physician telephone E/M services lasting 5–10, 11–20, and 21–30 minutes respectively.
When a telehealth visit is conducted across state lines, which state's billing regulations typically govern the claim submission?
Answer: The state where the patient is located
Payer rules and licensure requirements are generally governed by the state where the patient is physically located at the time of service.
Which of the following scenarios would most likely result in a telehealth claim denial due to place of service (POS) code error?
Answer: Using POS 02 for a video visit to a patient in a hospital outpatient clinic
POS 02 is for telehealth services provided to patients NOT in their home; POS 10 was introduced for telehealth when the patient is at home, so mixing these creates claim errors.