Question Authoritative guidance for platform on Telehealth

NESmith

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Plant City, FL
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Can anyone give me an authoritative guidance on whether you "must" have the location of the provider and the location of the patient documented in the medical record for Telehealth. Thank You!
 

Chelle-Lynn

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Modesto, CA
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Telemedicine does not have separate and specific documentation standard beyond what is normally required for the service being rendered. In the case of an office visit compliant, history, exam, and decision making would all still apply. Since the codes can be specific to the type of telemedicine such as video/audio, audio only, patient portal, it is recommended that for clarification the provider note which electronic device they are using to communicate with the patient.

Example:

1. Spoke with Jane Does via telephone for an audio only visit...
2. During an audio/video visit with the patient...
3. I was able to see the rash through the video connection with the patient
4. During a visit with the patient via the patient portal...

The location of the physician whether in the office or from their private home is relevant unless the carrier requires that the physician be in the office. Medicare has provided a waiver for the physician to practice both from home and the office, so the location is not a requirement for documentation.

Hope this helps. It can be a rather grey area; for documentation you will need to look at the carrier requirements for location, as well as what the coding guidelines require (ie: video, audio, patient portal).
 

csperoni

True Blue
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Selden
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I have seen that the location of the patient and the location of the provider should be documented. I don't believe it "MUST" be documented.
Here is a link to an AHIMA reference where they "RECOMMEND" having location of patient and location of provider. If I recall correctly, the reason for the location in telehealth is that a provider is licensed to provide medicine services in a particular state. During the emergency, there has been a relaxing of that requirement, but I see no reason not to document it. Additionally, location impacts reimbursement.
In our practice, when we create a telehealth note, the template has a place for both patient location and provider location. For patient, if you check the home radio button, the full patient address is populated for you. Alternately, you can check other and manually input whatever address you want. Similarly for provider, if you check office button, address is populated for you. If the provider is at home, we enter the city and state, but not their actual full home address.
If I come across a telemedicine note without provider and patient locations, I query provider to amend documentation.
 
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