medicalauditor
Networker
I realize that documentation requirements for telehealth may vary by state, but can someone point me to a resource which provides guidelines about how a telehealth service should be documented? I am looking specifically about the chart note clearly stating that the service was completed using a real-time, synchronous audio and video telecommunications system, and also identifying the system used. I am seeing providers simply stating it was a telehealth visit and billing office visit codes (99202-99215) without specifying that it was an audio AND video visit. I found that some visits were in fact telephone visits (audio-only) but were billed as OV & the chart note only said it was telehealth. Telehealth is a broad category of services and it does not tell me the exact mode of communication. As an auditor, I feel I should be able to verify if the visit was audio-video or not, so just stating "telehealth" is not enough, in my opinion. Moreover, if a visit was initiated as a "video" visit but due to technical issues, was primarily completed as a telephone visit, then the provider must bill telephone E/M codes and not OV codes. Due to these requirements, I like to see documentation that states the visit was completed using audio-video technology. However, as expected, I am getting push-back from providers about this not being a requirement, per current regulations. I think its just common sense and also best practice to clearly document that the visit was completed using audio-video, but if I can find specific guidelines or even just best practices for telehealth documentation from a trusted resource, it would help. Thank you!