Telehealth Documentation Guidelines

Are you following all the telehealth documentation guidelines? Do you even know what they all are? This is a field that is booming, and more and more people everyday are trying to get into it. What are the advantages of telehealth as far as a business owner and manager are concerned? For starters, your overhead is not as high because you aren’t trying to run an entire facility in order to keep it operational. Even if you are, you do not have to see patients inside the facility meaning you can see more and you can extend your hours, improving revenue. However, it’s not all that simple as you need to make sure that you are compliant with every regulation that is out there.

This is where you need to defer to your legal team to make sure you are not only compliant with existing rules, but aware of any new ones that come up, and there will be new ones. Again, this is a booming industry which means there are going to be policy changes and new guidelines implemented to ensure that patients get the best possible care. That’s why you need to make sure that you have a great legal team that is on the lookout for any changes and how they may impact you as you try to conduct business.

Current trends show that looking at records that are the subject of a telehealth or telemedicine visit doesn’t alert the reviewer to the fact that the transaction was done on a telehealth basis. This has led to a major increase in audit activity because the totality of the chart has no cohesiveness in the episode of care that the provider is documenting. Providers are seeing a patient in one state, documenting it in another and it is unclear from the record that it’s telehealth.

Telehealth documentation guidelines should at the very least contain space for the provider to say the patient’s name, identify where the patient resides and notate that the patient was seen pursuant to a telehealth or telemedicine visit.  Proper telehealth records should indicate that the provide and the patient meets the legal requirements for a telemedicine visit by the way that those documents are generated.

For example, if a patient has a diagnostic study and has a blood result and those results are sent in by the local physician to the telehealth provider then the documents should reflect that those results of the studies have been forwarded from another provider. The ordering physician should reflect that he/she did a telehealth visit in the evaluation or history/physical portion of their document. When a provider signs any orders or signs off on any services they should indicate where (which states) they hold licenses.

Technology for delivery of telehealth or telemedicine does have its drawbacks as well. Another important thing to remember when it comes to telehealth documentation guidelines is notes to the patient record that the transaction was clear. Meaning, you can see clearly and hear clearly. If a provider can’t achieve clarity in vision and sound during a telehealth visit then the provider should immediately terminate the transaction and reschedule it.

Remember that telehealth is not a substantive visit, but rather it is simply a delivery system of medicine. When providers do their documentation they must realize they are not delivering health care or medicine within the confines of a traditional brick and mortar office. Providers are now in a technology-based transaction that is subject to certain limitation. For instance, with a DME transaction that may require a back brace, how can a provider indicate that the patient was measured for a back brace? Without measurements, a flag will be thrown up right away. Payors will question not only how the patient was measured but will question whether it is overutilization. Providers utilizing telehealth must take special care to use best telehealth documentation guidelines and lead any reviewer, internal or otherwise, with effective documentation to understand how care was delivered.

The Florida Healthcare Law Firm is happy to assist you with any questions you have regarding telehealth documentation guidelines or anything else related to the industry. Our team specializes in this field and offers free blogs and monthly webinars that cover this and other important topics related to owning and operating a medical business. Feel free to check out these free resources or contact us if you still have any questions and we will be more than happy to assist you.

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