Documentation tips
Suggestions for documentation and billing
This is a high level overview of some best practices and considerations when it comes to both documentation and billing in relation to telehealth. The laws for each state and practice type may vary. This is also a rapidly evolving area of development so use this information only as a rough guide. Always follow the recommendations of your institution or practice.
Documentation for a telehealth visit should be the same as for other visits with some modifications.
Ensure that each visit has the following details:
- Provider Location
- Patient Location
- Established versus new patient
- Was the Consult performed using video? Yes/No
- Was verbal consent obtained?
- Date of consent obtained?
- Start time of appointment
- End Time
- Duration of the visit (needs to be at least 11 minutes for billing purposes)
- 3rd person or interpreter used? Yes/No
Parent Led Vitals
If parents have a scale ask them to get a weight of the child or baby.
If parents have a measuring tape: can measure height for child and head circumference (<24 months)
Special Considerations
Since the Video Visit will have a limited Physical Exam, the History section must support the Assessment & Plan.
Disclaimer
These documentation and billing tips are just meant to be a general guide. You should look to your local institution or clinic policies for more specific guidance.
By: Maria Rivera MD
Last updated: July 2020