With providers rapidly moving towards offering telehealth services many are seeking out best practices for this new service offering. One of the areas that providers must make sure to consider is the documentation requirements that may vary from a standard office visit.

In a document released by Optum, a health information technology and services firm that is part of UnitedHealth Group, they provide a list of specific requirements for virtual visit documentation that includes:

  • The need for telemedicine services
  • Mode of transmission
  • Time service started
  • Time the service ended
  • Location of the originating site, or where the patient is located at the time of service
  • Location of the distant site, or where provider is located at the time of service

In addition to the list above, payers are interested to see that you are using the time to support patient outcomes so be sure to include:

  • The percentage of time spent in consultation and coordination of care

For ease of entering this information into your chart note, you may consider building a new macro button in ChiroTouch. To give you a head start we have created an example of what you may want to insert on to a new macro button. The text in bold represents the Advanced Commands you would need to insert at specific locations to provide the necessary information:

This encounter occurred via synchronous video conferencing to enhance social distancing due to the COVID-19 pandemic. The patient was at home during the consultation and I was in my office. The session started at {Advanced Command= Number} and ended at {Advanced Command= Number}. Approximately {Advanced Command= Number} % of the time was spent on consultation and coordinate of care.

To review how to create a macro button with Advanced Commands watch this video:

While these elements have been added as requirements for telehealth services, the overall documentation requirements have not changed. As always, be sure that you continue to demonstrate medical necessity for this service if you anticipate a third-party payer will be involved in processing the claim, and follow all standard documentation requirements.

 

About Host, Dr. Tami Howard
Dr. Tami Howard is a ChiroTouch training manager and has been part of the ChiroTouch family since 2006. A graduate of Life University, Dr. Tami Howard and her husband own a chiropractic office in Michigan. Prior to pursuing a DC education, Dr. Howard was a chiropractic assistant. This practical experience on both sides of the office gives her valuable insights on how ChiroTouch can benefit staff as well as providers in creating efficiencies and automations that help offices work smarter, not harder.

 

ChiroTouch provides this information with the understanding that authors or speakers are not experts in finance, regulatory policy or law. ChiroTouch shares this information to the best of our knowledge and experience. The information is subject to change as the COVID-19 crisis evolves.

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