{"id":14959,"date":"2022-01-24T23:13:27","date_gmt":"2022-01-24T23:13:27","guid":{"rendered":"https:\/\/www.medicalbillersandcoders.com\/blog\/?p=14959"},"modified":"2024-12-04T10:17:14","modified_gmt":"2024-12-04T10:17:14","slug":"documentation-guidelines-for-telehealthcare","status":"publish","type":"post","link":"https:\/\/www.medicalbillersandcoders.com\/blog\/documentation-guidelines-for-telehealthcare\/","title":{"rendered":"Documentation Guidelines for Telehealthcare"},"content":{"rendered":"

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\u2019s 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.\u00a0<\/span><\/p>\n

Documentation Guidelines for Telehealthcare<\/span><\/h2>\n

Informed Consent:<\/strong> 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\u2019s needs. In the progress note, include a summary of the discussion and the patient\u2019s decision, as well as a copy of the signed form.<\/span><\/p>\n

Mode of Telehealth:<\/strong> While documenting the medical record, clearly specify what mode of telehealth is being used. You can mention \u2018secure interactive audio-video session using Skype,\u2019 \u2018medication management visit conducted by telephone,\u2019 or \u2018asynchronous diagnostic test follow-up by portal\/text\/email.\u2019<\/span><\/p>\n

Confirm Patient Identity:<\/strong> 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.<\/span><\/p>\n

Location:<\/strong> Document the patient\u2019s physical location and geography. For example, including \u2018at her home in Tennessee\u2019 is important for billing purposes<\/a> and for determining venue in the event of regulatory or professional liability action. Also include the provider\u2019s location (\u2018clinic name and city\u2019 or \u2018home office and city\u2019) in the documentation.<\/span><\/p>\n

Appropriateness:<\/strong> 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 \u2018the visit was rescheduled at the patient\u2019s request because her husband could not be available.\u2019 Evaluate and address distractions in the environment. Carefully document the patient assessment and environmental conditions as well as any actions taken and recommendations made.\u00a0<\/span><\/p>\n

Others Present:<\/strong> Document the record with the name and relationship of everyone who is present on the patient\u2019s side of the interaction and the names and roles of everyone present on the provider\u2019s side. The patient\u2019s family members may be present, or the patient may be a minor. For example, document \u2018visit conducted with a child sitting on mother\u2019s lap.\u2019 Clinical assistants, students, or ascribe may be present on the provider\u2019s side. Include documentation of all participants.<\/span><\/p>\n

Assisted Assessment:<\/strong> 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 \u2018patient provided.\u2019 If patients also assist in various aspects of physical examination, document the details as \u2018patient assisted.\u2019\u00a0<\/span><\/p>\n

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. <\/span>MedicalBillersandCoders (MBC)<\/b><\/a> is a leading outsourcing medical billing company<\/a> 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 info@medicalbillersandcoders.com<\/a>\/ 888-357-3226<\/span><\/p>\n

FAQs<\/h2>\n

1. Why is documentation important for telehealthcare?<\/strong><\/h3>\n

Documentation is crucial for establishing medical necessity, ensuring regulatory compliance, and supporting claims during audits. Accurate documentation helps secure proper reimbursement for telehealth visits and meets both state regulations and insurance carrier expectations.<\/p>\n

\n

2. What are the key documentation guidelines for telehealthcare?<\/strong><\/h3>\n

Important guidelines include informed consent, confirming patient identity, documenting the mode of telehealth used (audio-video, telephone, etc.), confirming the patient’s location, assessing appropriateness of the visit, and documenting anyone present during the session (patient\u2019s family, assistants, etc.).<\/p>\n

\n

3. How can I confirm patient identity during a telehealth visit?<\/strong><\/h3>\n

You can confirm a patient\u2019s identity by asking them to hold a photo ID close to the camera at the beginning of the telehealth session. Document this confirmation along with any identification requests from the patient for the provider.<\/p>\n

\n

4. What should be documented if the patient\u2019s environment is not suitable for a telehealth visit?<\/strong><\/h3>\n

If the environment is not appropriate for a telehealth visit (e.g., due to cognitive status or lack of support), document the assessment, including reasons for rescheduling or canceling the visit. For example, you might note, “Visit rescheduled because patient\u2019s husband was unavailable to assist.”<\/p>\n

\n

5. How can outsourcing medical billing help with telehealthcare documentation?<\/strong><\/h3>\n

Outsourcing medical billing to experts like MedicalBillersandCoders (MBC) ensures that your documentation meets payer-specific and state-specific requirements, reducing errors and improving reimbursement accuracy. For more details, contact us at info@medicalbillersandcoders.com<\/a> or 888-357-3226.<\/p>\n","protected":false},"excerpt":{"rendered":"

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\u2019s contracts outlining medical necessity expectations and state regulations that […]<\/p>\n","protected":false},"author":2,"featured_media":14960,"comment_status":"closed","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2],"tags":[3161,3162,11,3163],"class_list":["post-14959","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-medical-billing-services","tag-boost-your-medical-practice-revenue","tag-guidelines-for-telehealthcare","tag-medical-billing-outsourcing","tag-outsourcing-meedical-billing"],"yoast_head":"\nDocumentation Guidelines for Telehealthcare<\/title>\n<meta name=\"description\" content=\"Guidelines for Telehealthcare can facilitate public health mitigation strategies during this pandemic by increasing social distancing.\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, 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