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Documenting Telehealth Encounters During COVID-19

Yolanda Sims, JD, MHA
Loss Prevention & Risk Management Advisor
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Due to the rapid onset of COVID-19, there has been increased engagement in telehealth and phone visits in place of in-person care. Telehealth is being used in most care settings nationwide. This mode of care presents some unique considerations healthcare professionals should review to ensure competent care is given. According to the Centers for Medicaid and Medicare (CMS), there are four main types of virtual services physicians and other professionals can provide patients during the COVID-19 crisis.  
  • A Virtual Visit: A real-time clinical encounter using technology that supports real-time communication between clinician and patient.
  • Virtual Check-in: A short patient-initiated action, after which the clinician and patient have already had a face-to-face encounter or Virtual Visit, and the patient wants to touch-base.
  • E-Visit: Non-face-to-face patient-initiated communication through an online patient portal.
  • Telephone services: An encounter in which a physician or qualified healthcare professional provides evaluation, management, and services via a telephone call or online app.
CMS has temporarily relaxed the regulatory requirements that apply to telehealth services. It is important to note coverage and payment vary across payers; thus it is highly recommended to review current billing practices. To learn more about billing and coding reimbursement with telehealth services, please see the linked CMS Fact Sheet.

The Department of Health and Human Services Office for Civil Rights has granted health professionals flexibility and discretion to provide care using a variety of modalities. Previously, some videoconferencing technologies such as Skype, Facetime, and Zoom were not deemed HIPAA-compliant, but in light of COVID-19, they are permitted. To make certain you are appropriately adapting to delivering care through technology, review the following risk management recommendations:

 
1.   Use a Specific Telehealth Consent Form
    A traditional informed consent document thoroughly explains the type of care and treatment the patient is agreeing to as well as the risks and benefits. A telehealth informed consent document does the same, but it focuses on the medium by which care is being delivered as well as the limitations of the service. In addition, privacy and security concerns should be discussed with the patient. Explain to them, despite the effort to provide care in a secure environment, all electronic medical communications carry some level of risk.
SAMPLE TELEMEDICINE CONSENT FORM
 
2.   Patient Suitability
    Using your clinical judgment, determine if a telehealth service is suitable for your patient’s individual situation and medical needs. Patients exhibiting signs of breathlessness, extreme fatigue and other concerning symptoms should not be evaluated via technology. The American Telemedicine Association recommends providers create an initial list of services they think are best handled using face-to-face encounters and those best handled via telehealth. This plan ahead strategy will allow you to best triage your patients according to their presenting condition(s).
 
3.   Documentation is Key
    Whether over the phone or video, document telehealth encounters the same as you would face-to-face visits. Data to document includes the information about the visit, the history, review of systems, consultative notes, images, pictures, and any information used to make a medical decision about the patient. This documentation is also essential for reimbursement purposes.
 
4.   Safety Netting Advice
    Because we are experiencing a health crisis, it is important to give clear safety netting advice when providing telehealth services. Safety netting advice is information given to a patient during a care visit regarding actions they should take if their condition fails to improve, changes, or if they have further concerns. One way to note how you incorporated this concept is to document the following information in the chart:
  • Document and explain uncertainty to the patient.
  • Identify the specific clinical features the patient should look out for.

Example: Here are signs to look for that might indicate things are getting worse. If you become significantly breathless or develop pains in your chest, then you should seek urgent medical advice.

  • Give guidance on how and when to seek further help, if needed.
  • Provide a time course that will aid the patient while at home until the next encounter. But explain to them if they have concerns that arise, do not delay seeking further medical advice.

Please note, information regarding successes and challenges to providing telehealth during a pandemic will continue to be shared as the topic evolves. KAMMCO will continue to keep you updated as we become aware of new developments. To help guide your documenting efforts, below is an example to use and modify as needed of how you may begin your initial documentation of a telehealth encounter:

Example: I am seeing this patient today virtually using Skype, a permissible modality during the COVID-19 crisis. The patient has previously provided full consent to use this technology and understands the risk and benefits of proceeding. I am seeing the patient today from my office in CITY, STATE, and from their home located within STATE.

For more information and resources on the COVID-19 crisis, please visit the COVID-19 Resources section of the KAMMCO Risk Management Tools and Resources page.   

This document should not be interpreted as medical or legal advice. Because the facts pertaining to your situation may fluctuate, or the laws in your jurisdiction might vary, please contact your attorney if you have questions related to your legal or medical obligations or rights, state or federal laws, contract interpretation, or other legal questions.


References
Almond S, Mant D, Thompson M. Diagnostic safety-netting. British Journal of General Practice. (2009)

ATA’s Quick-Start Guide to Telehealth During a Health Crisis. American Telehealth Association. (2020) Retrieved April 20, 2020 from https://www.americantelemed.org/covid-19/?hsCtaTracking=8d2c6133-9994-45dd-9f73-b4fe45e82edb%7Cdd37320a-f824-4017-abec-5020655f060d

Medicare Coverage and Payment for Virtual Care. (March 2020). American Hospital Association. Retrieved April 20, 2020 from https://www.aha.org/system/files/media/file/2020/04/COVID-19-telehealth-video-medicare-coverage-payment.pdf

Ethical Practice in Telemedicine. (n.d.) Code of Medical Ethics Opinion1.2.12. American Medical Association. Retrieved April 20, 2020 from https://www.ama-assn.org/delivering-care/ethics/ethical-practice-telemedicine

Telehealth: Rapid Implementation for Your Cardiology Clinic. (March 2020). American College of Cardiology Foundation. Retrieved April 17, 2020 from https://www.acc.org/latest-in-cardiology/articles/2020/03/01/08/42/feature-telehealth-rapid-implementation-for-your-cardiology-clinic-coronavirus-disease-2019-covid-19

Neighbor R, Stockely, S. Top 10 Tips for COVID-19 Telephone Consultations. (March 2020). Royal Colleges of General Practitioners. Retrieved April 21, 2020 from https://www.rcgp.org.uk/about-us/rcgp-blog/top-10-tips-for-covid-19-telephone-consultations.aspx