How should I document a telehealth visit?  As with all professional services, proper coding and timely reimbursement are dependent upon complete and accurate documentation. Here you will find best practices for documenting a telehealth visit.  Documentation requirements for any form of virtual care (telehealth service or non-telehealth virtual communication services) are the same as those for documenting in-person care so you should include everything you usually need to document for the CPT or E&M code being billed.  In addition, for a telehealth encounter, it is strongly recommended (though not necessarily required) for you to document the following:

• Patient's Location (with enough detail to satisfy a Medicare audit, i.e., eligible facility in an eligible geographic location).
  • There have been many exceptions made during this pandemic as a result of the different waivers, so this is not as important during the Public Health Emergency and its unwinding, but in general you should do this so you might as well make it a practice!
  • If the patient's home is the location of service, and the address is already somewhere in the medical record, then you just need to include in your note that the visit took place at the patient's home.  You do not need to capture the address again.
  • It is always good practice to verify the patient's location at the start of every virtual visit.  Do not assume they are at home!  Remember that if the patient experiences an emergency/crisis when they are in the middle of a visit with you, if you don't have easy access to the address of their physical location (a PO Box will not work), it will be impossible to contact first responders and have them deployed to the patient's location.  See "Best Practice" information below!
  • We have encountered situations where the patient is actually traveling (e.g, in a car) during a telehealth visit.  Should this be the case, note that the patient was in a vehicle, but do ask what State the patient is in.  Note this in the patient record to ensure documentation of compliance with any licensure requirements.

• Provider's Location (under normal circumstances, this would be the usual place of practice – for most, it would be the office location, but if home is a routine or the only office location, then the provider’s home location should be registered as a site of service and used).  With that said, please note that during the period of the Public Health Emergency and its unwinding, CMS has been allowing physicians and other practitioners to render telehealth services from their home without reporting their home address on their Medicare enrollment form while continuing to bill from their currently enrolled location(s).  This is likely to change at the start of 2024.

• Type of Encounter and Telehealth Technology Used.  It is important here to indicate whether the visit was:  1) synchronous or asynchronous and then 2) the type of technology (or technologies) used:  telephonic (audio-only), video, telemetry/remote physiologic monitoring, patient portal communications, etc.

• Start and Stop Time/Total Time (documentation for billing requires total time spent by the physician or other qualified health care professional on the date of encounter for all activities related to that patient and/or the medical decision-making).  If the total time spent with the patient/client is via telehealth, you can simply document the start and stop time of the telehealth visit.  Otherwise, you should document total time spent on the date of encounter, inclusive of all other activities pertaining to the patient and/or the medical decision-making.  Some payers may want the actual start/stop time of the telehealth visit in addition to the total time, so it doesn't hurt to document both.
  • If you are using office visit codes (99202 - 99215), CMS is allowing you to choose between time or medical decision making (MDM).  When reporting the office visit codes, you are not required to include the time, but it is still strongly recommended.  Should you ever be audited, it will be easier to track back in the records and verify that a telehealth visit actually took place if you have the actual time frame.

• Consent (unless otherwise documented).  Please refer to your State's laws/licensing board regulations and guidance documents regarding specific requirements.  See section on consent for how to do this.

• Others Involved or Present including other providers like tele-presenters, family members/care-takers or simply the presence of other individuals in the room with the patient during the visit.  Disclosure of others involved/present by both the patient and the clinician and documenting will  provide a level of protection against complaints related to HIPAA violations.

• Reason/Criteria for Telehealth (medical or otherwise).  Include here any criteria used to evaluate whether the case was appropriate for a telehealth visit, referencing any existing protocols your practice/organization has around this. If the visit was audio-only (telephonic), it is also recommended that a reason be documented (e.g.., no internet access, no access to video enabled device, could not get technology to work, etc.)

• Emergency and Non-Emergency Numbers:  Should your patient have a medical or mental health emergency, having the provider dial 911 if the patient is not in the same jurisdiction as the provider may cost valuable time as the 911 system is locally run.  It is recommended that you document somewhere in the patient record both an emergency and non-emergency number for the town/location of the patient (either their home or wherever they typically go when they have their telehealth visits).
  • Emergency Number:  You may find the emergency number by using a Google search using the city/county/jurisdiction of the patient.  This number should be verified/updated at least a few times a year because they can change.  If your patients are at high risk for having emergent needs, you may want to consider purchasing access to the NENA PSAP  Registry Database which is more precise because it takes into consideration actual street address and stays up-to-date.
  • Non-Emergency Number.  Often in a standard patient intake form, patients are asked for an "emergency contact" (family, friend, etc).  This emergency contact may/may not reside in the same jurisdiction as the patient.  It is a good idea to ask if the patient could provide you with a contact (friend, neighbor, family member) that lives in the same jurisdiction as the patient...someone who can easily run over to check on them if needed.  This is useful if you need someone to conduct a welfare check on a patient.  Calling law enforcement for this purpose can be traumatizing for some individuals.  If the patient is unable/unwilling to provide you with a contact, then you should also document the non-emergency number in the patient's jurisdiction.  This number should also be verified at least a few times a year.