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Document Telehealth Therapy & Mental Health Visits W/ Ease

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Document Telehealth Therapy & Mental Health Visits W/ Ease

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Telehealth therapy

It’s become more common than ever to see mental health patients via telehealth, providing convenience and time savings to those who prefer it. In most cases, you’re probably able to collect for telehealth therapy encounters without an issue, but that’s not the end of your responsibility. You should also document appropriately so you can support the medical necessity of these visits and hang on to your deserved pay.

Check these seven tips to ensure you’re documenting all the most important factors when you perform telehealth therapy and other mental health visits.

Document the Telehealth Therapy Method

Most payers will allow you to perform these visits in a variety of ways, but you should always document the method you end up using. For instance, “I saw Mrs. Smith virtually today for psychotherapy using a secure two-way interactive video connection…”

Record the Provider and Patient Locations

While not all payers require you to record the provider and patient location at the time of the encounter, many do — so the easiest way to comply is to document it for every patient. If you get into that habit, you’ll never leave out these details when those who require it come looking for records. For instance, “I saw Mrs. Smith, who was located in her home. I was located in my clinic.”

List All Clinical Participants

All clinical staff members who participated should have their names recorded in the record, along with notes about their roles and actions. For instance, “Mrs. Jones’ caseworker joined the call to discuss her care plan for when she’s discharged from her rehab facility.”

Confirm Time Spent

Many of the codes you’ll be reporting for telehealth services require you to know how much time was spent with the patient, so always include that information in the medical record. Psychotherapy codes are based on time spent, and you can choose time as your code selection method for E/M visits as well.

When leveling the E/M visit based on time, always document the total time – face to face and non-face to face.

When billing for straight psychotherapy, always note the total time – the codes are chosen based on time. Remember this is face to face time, since non-face to face time does not count toward the psychotherapy code level.

Document Patient Consent

Providers must document confirmation that the patient agreed to receive services via telehealth. Verbal consent to receiving telehealth is an acceptable method but must be documented in the medical record – this does not have to be done at each visit, but you should have a document in the chart supporting the fact that the patient consented to telehealth services. Update this annually when you have the patient sign your updated financial and HIPAA policies at the beginning of each new year.

Summarize the Visit and Progress to Goals

Psychotherapy notes must always include documentation that summarizes the mental health session and shares the patient’s goals, as well as their progress toward meeting those goals. For instance, “Mrs. Smith and I discussed her progress toward leaving the house at least once a day, and she is doing well, reporting that she left the house twice on Tuesday and once on Monday, with a new goal to take a walk every morning.”

Assert That Phone Calls Weren’t Related to Recent E/M

If your telehealth visit took place over the phone, document whether the telephone call was patient-initiated, how long it took, what was discussed, and confirm that the patient verbally consented to the service. In addition, you should also assert that the call was not related to a service performed and reported within the previous seven days (such as an in-office E/M visit).

You can bring in significant pay for your mental health telehealth services if you perfect your documentation and coding practices. Let nationally-recognized physician and consultant Dreama Sloan-Kelly, MD, CCS, CPC, lead the way during her online training, Stop Errors & Boost Pay for Telehealth Services for Mental Health. Register today! 


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