Foundations for Charting & Coding - Session 9

Telehealth has become part of routine care, but documenting a virtual encounter requires more than simply noting that the patient was seen by video or telephone.

We’ll review what should be captured in the record to support a telehealth service, including the modality used, patient and provider location when required, consent, participants, the clinical work performed, and the elements necessary to support the reported E/M service through MDM or time when applicable.

We’ll compare telehealth documentation with traditional in-person E/M documentation and discuss what changes – and what doesn’t – when the patient and provider are not physically in the same room.

We’ll also address common trouble spots, including audio-only versus audio/video encounters, payer-specific requirements, modifiers and place of service considerations, and distinguishing a true billable telehealth encounter from portal messages, brief communications, education, or other virtual interactions.

The goal: make sure the chart clearly demonstrates what happened, how the service was delivered, and why the service billed is supported.

Join experienced billers Nancy Koerber and Marnie Cabezas as they guide you through the mechanics of modern documentation and billing. This series is designed to establish a rock-solid foundation for your practice’s long-term financial health.

For access to previously recorded sessions and full details on the series, visit: 

Foundations for Charting and Coding

Presenters