Documentation Guidelines for Telehealthcare

Documentation requirements for telehealthcare are identical to those of onsite medical care. Documentation plays a significant role in establishing medical necessity for billing; adhering to regulatory compliance; and supporting your claim in case of internal and external audits. Documentation rules may change as per insurance carrier’s contracts outlining medical necessity expectations and state regulations that define what constitutes telehealth. Irrespective of payer-specific expectations and state regulations, there are some documentation guidelines for telehealthcare, following them will ensure compliance and accurate insurance reimbursements. 

Documentation Guidelines for Telehealthcare

Informed Consent: Advice patients before asking them to consent to treatment by telehealth, about the unique risks of a telehealth visit, including the potential for technical difficulties, information security concerns, and the potential for converting the visit to an in-office visit based on the patient’s needs. In the progress note, include a summary of the discussion and the patient’s decision, as well as a copy of the signed form.

Mode of Telehealth: While documenting the medical record, clearly specify what mode of telehealth is being used. You can mention ‘secure interactive audio-video session using Skype,’ ‘medication management visit conducted by telephone,’ or ‘asynchronous diagnostic test follow-up by portal/text/email.’

Confirm Patient Identity: Confirm the identity of new patients before starting the telehealth session. You can ask them to hold a photo ID close to the camera. Document confirmation of patient identity. On the other hand, patients also have the right to ask for provider identification.

Location: Document the patient’s physical location and geography. For example, including ‘at her home in Tennessee’ is important for billing purposes and for determining venue in the event of regulatory or professional liability action. Also include the provider’s location (‘clinic name and city’ or ‘home office and city’) in the documentation.

Appropriateness: Determine quickly if the patient and environmental conditions are appropriate for a telehealth visit. Some patients may not be appropriate based on their cognitive status. If the patient is unable to answer questions or provide an accurate history and no support person is available, the visit may need to be rescheduled. Documentation in this situation might include ‘the visit was rescheduled at the patient’s request because her husband could not be available.’ Evaluate and address distractions in the environment. Carefully document the patient assessment and environmental conditions as well as any actions taken and recommendations made. 

Others Present: Document the record with the name and relationship of everyone who is present on the patient’s side of the interaction and the names and roles of everyone present on the provider’s side. The patient’s family members may be present, or the patient may be a minor. For example, document ‘visit conducted with a child sitting on mother’s lap.’ Clinical assistants, students, or ascribe may be present on the provider’s side. Include documentation of all participants.

Assisted Assessment: Plan in advance and provide instructions for patient assistance, such as for patients who will obtain and report their own vital signs (including weight, blood pressure, pulse, and temperature). Document the information in the medical record as ‘patient provided.’ If patients also assist in various aspects of physical examination, document the details as ‘patient assisted.’ 

Above mentioned documentation guidelines for telehealthcare can help you ensure that your documentation is patient-centered, comprehensive, and effective. Additional details may be required as per regulatory and payer requirements specific to your practice location(s). If you are finding any difficulty in documentation or struggling to get accurate reimbursements for telehealthcare, you can contact us. MedicalBillersandCoders (MBC) is a leading outsourcing medical billing company providing complete revenue cycle services. Our billing experts are well versed with state-specific and payer-specific documentation requirements. To know more about our telehealthcare billing services, contact us at 888-357-3226