Ob-Gyn Coding Alert

Question: When doing a telehealth encounter, do you need to ask for telehealth-specific consent for the patient?

Alabama Subscriber

Answer: During the COVID-19 public health emergency (PHE), many of the regulatory requirements surrounding telehealth encounters were waived, and providers and patients could connect more easily, on widely available platforms like FaceTime, which were not necessarily compliant with HIPAA. Now that the PHE is over, stakeholders need to adjust their practices to remain in compliance — and secure reimbursement.

But, to put it bluntly: Yes, you must make sure you have consent in the medical record for a telehealth encounter, says Leonta “Lee” Williams, MBA, RHIA, CPC, CCS, CPCO, CCDS, CEMC, CHONC, CRC.

Consent during a telehealth encounter can be an important legal consideration. You should also document properly the audio/visual component of the encounter, which designates the encounter as telehealth, versus an audio-only service.

The Centers for Medicare & Medicaid Services (CMS) suggests following these best practices, regardless of state laws:

• When you meet with a patient, explain what they can expect from the telehealth visit and list their rights.
• Check in with the patient about their responsibilities during a telehealth visit, such as maintaining privacy.
• If there is anyone observing the visit, tell the patient and get their consent at the beginning of the visit.
• Don’t record a visit.

Congress and federal agencies are still hammering out the details for which aspects of the telehealth-related PHE waivers will become permanent versus which regulations will revert to pre-PHE constraints.

Visit the CMS website to find out more about telehealth for providers.