Documentation Required For Telehealth

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Frequently Asked Questions

What should be included in the documentation of a telehealth visit?

The information of the visit, the history, review of systems, consultative notes or any information used to make a medical decision about the patient should be documented. Documentation should include a statement that the service was provided through telehealth.

What are the patient consent requirements for telehealth?

Patient consent Providers must document confirmation that a member agrees to receive services via telehealth, verbal consent to receiving telehealth is an acceptable method but must be documented in the medical record Other documentation requirements are the same as a face-to-face encounter

What is the hcpcs code for telehealth services?

The originating site should report HCPCS code Q3014 for the services provided. Documentation requirements for a telehealth service are the same as for a face-to-face encounter. The information of the visit, the history, review of systems, consultative notes or any information used to make a medical decision about the patient should be documented.

What are the legal requirements for telemedicine?

Each state has its own legal requirements for telemedicine, so make sure you research what your state requires for documentation. Just as you need to adapt your tools and equipment to telemedicine visits, you also have to adapt your documentation to telemedicine.