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 document the following for a telehealth encounter:

  • Patient's Location
    • Detail the 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).
    • Note if at Home:  If the visit occurs at the patient's home, and the address is already recorded, simply state that the visit took place at 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.
    • Traveling Patients:  If the patient is traveling (e.g., in a vehicle, in a hotel room out of town), note this, including their current state to ensure licensure compliance.  .
  • Provider's Location
    • Document Provider's Location.  Typically, this would be your usual place of practice (e.g., office or home or other registered site of service).
  • 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.
  • Consent
    • Document Consent:  Follow your state's laws and regulations regarding patient consent for telehealth.  Document the consent process if not previously documented.
  • Others Involved or Present
    • List Other Participants:  Note the presence of other providers, family members or anyone else in the room.  Patient and clinician disclosures of others present helps ensure privacy and compliance with HIPAA.
  • Reason for Telehealth
    • Document Telehealth Appropriateness:  Include the reason or criteria for using telehealth, referencing existing protocols if they exist (e.g., distance, patient preference).  If using audio-only, provide brief explanation (e.g., no access to video-enabled device, lack of internet access, patient refuses video).
  • 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:
      • Using a search engine and looking up the city/county/jurisdiction of the patient OR
      • If you work with high-risk patients, purchasing access to the NENA PSAP  Registry Database which is more precise because it takes into consideration actual street address and is kept up to date.
    • 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.