How should I document a telehealth visit?  Accurate documentation is essential for coding, compliance and timely reimbursement.  Here are best practices for documenting a telehealth visit.  Requirements for documenting telehealth are generally the same as for in-person care, so be sure to include all standard documentation needed for the CPT or E&M code.  Additionally, it is recommended that you also document the following for telehealth encounters:

At Every Visit:

  • Patient's Location: Document the patient's location in enough detail to meet audit requirements, especially for Medicare (e.g., eligible facility in a qualifying geographic area). Even though we are still under an extension of the PHE waivers, this is a good habit to get into in case things change!
    • If Patient is at Home:  If the patient is at their home, and the address is already in the patient record, simply verify that they have not moved and document that the visit took place at the patient's home.  Verifying location at the start of each virtual visit is a best practice.  In case of emergencies during the visit, knowing the patient's exact location allows you to quickly alert first responders.
    • If Patient is Traveling:  If the patient is traveling (e.g., in a hotel room, at a friend or family member's home), note this, including their current state to ensure licensure compliance.
  • Provider's Location: Typically, this would be the provider's usual place of practice (e.g., office or home or other registered site of service). On occasion, the provider could be in a temporary location.  Make sure you make note of this as well.
  • Type of Encounter and Technology Used
    • Specify Enouncter Type.  Indicate whether the visit was synchronous (real-time) or asynchronous.
    • List Technology Used. Document the technology utilized, such as audio-only (telephonic), video, remote monitoring, or patient portal communications.
  • Start and Stop Time/Total Time
    • Document Time Spent:  For billing, document the total time spent on the encounter, including start and stop times if telehealth-specific or list total time on the encounter date if other activities related to the patient and/or medical decision making are involved.  Some payers require both total time and start/stop times, so it doesn't hurt to document both.
    • Time vs. Medical Decision Making: CMS allows office visit codes (99202 - 99215), to be selected based on either time or Medical Decision Making (MDM).  Including time documentation, even when using MDM, can be helpful for audit purposes.
  • Others Involved or Present:  Note the presence of other providers, family members or anyone else in the room on both the patient and provider's side.  Patient and clinician disclosures of others present helps ensure privacy and compliance with HIPAA.
  • Reason for Telehealth:  While rarely required, including brief note about the reason or criteria for using telehealth is sometimes of value; this is particularly important if using audio-only.  Provide a brief explanation (e.g., no access to video-enabled device, lack of internet access, patient refuses video).

On a Regular Basis:

  • Consent:  Ensure compliance with your state's laws and regulations regarding patient consent for telehealth services.  Document the consent process if not previously documented.  As a best practice, review and update the consent documentation annually to maintain accuracy with changes in your office's use of technology and workflow and alignment with current legal and regulatory requirements.  Click HERE to learn more about telehealth informed consent best practices.
  • Emergency and Non-Emergency Numbers: 
    • Emergency Number:  For patients outside your jurisdiction, record the emergency number specific to their location, as 911 is specific to the location of the caller.  Consider checking and updating these numbers periodically by:
    • Non-Emergency Number.  Ask the patient to provide a local contact (friend, neighbor, family member) for welfare checks if needed (preferred method).  If unavailable, document the non-emergency number for the patients' jurisdition and update this information regularly.  Remember that calling law enforcement for welfare checks can be traumatizing for some individuals.