How do you train and update your staff on telehealth documentation and coding standards?

1 Know the rules and guidelines

Different payers, such as Medicare, Medicaid, and private insurers, may have different requirements and policies for telehealth documentation and coding. For example, some may require specific modifiers, place of service codes, or diagnosis codes to indicate telehealth visits. Others may have different reimbursement rates or coverage criteria for telehealth services. You need to stay updated on the latest rules and guidelines from each payer and communicate them to your staff. You can also use online resources, such as the American Medical Association (AMA) or the Centers for Medicare and Medicaid Services (CMS), to find telehealth coding guidance and FAQs.

2 Train your staff on telehealth documentation best practices

Telehealth documentation should follow the same principles and standards as in-person documentation, such as being accurate, complete, timely, and consistent. However, telehealth documentation also needs to capture some additional information, such as the type and mode of telehealth service, the patient's location and consent, the provider's location and credentials, the reason for choosing telehealth, and any technical issues or limitations. You should train your staff on how to document these elements clearly and appropriately, using templates, checklists, or tools if available. You should also review your staff's documentation regularly and provide feedback and coaching as needed.

4 Educate your patients on telehealth documentation and coding

Your patients are also part of your telehealth documentation and coding process, as they need to understand what telehealth services entail, what their rights and responsibilities are, and how they will be billed. You should educate your patients on these aspects before, during, and after each telehealth visit, using clear and simple language. You should also provide your patients with written information, such as consent forms, visit summaries, billing statements, and educational materials, that explain the telehealth documentation and coding process. You should also encourage your patients to ask questions, raise concerns, or report errors if they notice any.

5 Stay updated on telehealth trends and changes

Telehealth is a dynamic and evolving field, which means that the documentation and coding standards may change over time. You should stay updated on the latest telehealth trends and changes, such as new regulations, policies, codes, or guidelines, that may affect your practice. You should also monitor your telehealth performance and outcomes, such as patient satisfaction, quality indicators, revenue cycle, and compliance audits, to identify any gaps or opportunities for improvement. You should also seek feedback from your staff, patients, and peers on how to enhance your telehealth documentation and coding process.