Telemedicine Documentation Guidelines for Compliance

Telemedicine Documentation Guidelines for Compliance

Telemedicine Documentation Guidelines for Compliance

Telemedicine has been considered part of the standard of care for most major healthcare systems for years, but the coronavirus pandemic brought new challenges to providing patient care as well as tighter telemedicine documentation guidelines for compliance.

In response, the Centers for Medicare & Medicaid (CMS) loosened restrictions on qualifying conditions for telehealth practice and commercial payors began reimbursing providers for telemedicine.

Patient encounters were poorly documentedEven before the pandemic, there were concerns about the possibility of waste, fraud, and abuse from telemedicine. One of the largest audits of telemedicine was conducted by the Office of the Inspector General (OIG) into South Carolina’s Medicaid telemedicine services. At the time, nearly 96% of patient encounters were poorly documented, leaving the providers open to denial of or reversal of payments.

Essentially, the OIG’s South Carolina investigation revealed significant issues with the documentation practices of the healthcare providers. As a result of their findings, the OIG recommended that providers be given “formal training on telemedicine documentation requirements and enhance the monitoring of provider compliance by conducting periodic reviews of telemedicine payments for compliance with documentation requirements.”

Following Best Practices

Ensure patient records meet guidelinesTelemedicine documentation guidelines for compliance should closely follow most of the best practices already in place for EHR in your organization. Using your established guidelines for documentation will ensure your patient records continue to meet current state and federal guidelines as well as those established by individual insurance payors.

When conducting patient care using telemedicine, providers should also take special care to include the following so auditors, reviewers, and payors can understand how care was delivered:

• Clear consent of the patient to engage in the telemedicine visit.
• The method of telehealth delivery (audio only or synchronous audio and video)
• Notation that the provider could clearly hear or see the patient throughout the visit.
• Physical location of the patient and provider.
• Total length of visit with clear start and stop times indicated.

Telemedicine Versus In-Person

It is implied by the nature of telemedicine delivery that certain elements of the physical exam cannot be performed but objective observations of the patient should always be properly documented.

Remain cognizant of HIPPA guidelinesIf you have a patient who supplies information during the visit from personal equipment such as a scale or blood pressure machine, encourage patients to allow you to observe the collection of the data that is being reported.

Providers should remain cognizant of HIPAA guidelines and stay abreast of changes that affect telemedicine delivery and maintenance of electronic protected health information (ePHI).

Anytime, Anywhere Access to Mission-Critical Data Can Improve Patient Care

All healthcare organizations should have a system of secure communications that allows for monitoring communications to prevent accidental or malicious breaches of a patient’s private information.

Since healthcare data breaches cost an average of $9.42 million, protecting your organization and your patients’ private information from bad actors is more important than ever, especially as healthcare moves toward a contactless delivery system with more endpoints and networks that lack discernable perimeters.

The right IT provider can help address the unique security challenges facing today’s mobile and highly connected healthcare providers. Ensure your organization meets all regulatory audit requirements by establishing policies that only allow for access to protected health records based on the context of the user, regardless of device or login location.

These protocols also create a clear audit trail that prepares your organization for rapid response to compliance incidents and to any investigations that occur after the fact with cloud-based solutions that monitor, log, and report in real time.

Patients with technological challengesPhysicians should use reasonable and appropriate safeguards to maintain the integrity of transmitted ePHI while also being understanding of some of the challenges presented by the technological skills of certain patient populations. Seniors may need assistance from family members to access files or records. Acknowledge the consent of the patient and the relationship of the person who is given permission to access the data.

Since the clarity of the patient encounter is a crucial part of documentation guidelines, part of the best practices for telemedicine are making sure you have a stable platform. Can patients access a secure telemedicine platform that will still perform reliably with the available bandwidth on the patient’s mobile device or desktop? If you’re ever unable to achieve visual or auditory clarity during a telehealth visit, you should take steps to reschedule the appointment.

Encrypt all communicationsAny system used for telehealth should ideally encrypt all communications including images, videos, or documents to make them unreadable should they be intercepted over public Wi-Fi networks.

Almost every physician has a telemedicine tale of a patient attempting to conduct a visit while shopping for groceries. Assume any telemedicine visit will be conducted over an unsecured network on the patient side.

Good telemedicine documentation begins with following traditional in-person charting guidelines and layering in essential notations that make it easy for reviewers to understand from the record that the patient was seen using telehealth.

Keep Your Patient’s Data Secure

Monitor insurer guidanceEven with the technological improvements for the delivery of telemedicine and the increased reimbursements for patient care administered over secure virtual platforms, regulations and reporting standards are sure to change. To keep compliant, continue to monitor all state, federal, and commercial insurer guidance to maintain patient records accurately.

Position your practice to meet the future of patient care delivery while maintaining sensitive patient data in an era of increasing regulatory oversight, by scheduling a demo of our virtual desktop hosting and applications for the healthcare industry.

Having one comprehensive IT solution reduces the administrative burden and allows healthcare providers to focus on their primary mission: delivering the best care to patients. Speak to a CyberlinkASP IT healthcare specialist now, to find the right solution for you.