Document TeleMedicine & Virtual Care Encounter

Providers use different encounter templates to help differentiate between their various in-office visits. For example, a contact lens visit typically involves fewer, or more specific, tests than a comprehensive exam so a different template is often used to account for these differences.

Virtual visits can also take different forms depending on the care being provided. Accordingly, the decision about how to document them should consider that fact. As an example, an e-visit (e.g., PHR-based messaging) will not involve any aspects of a physical exam whereas a telehealth visit very well might. Thus, the templates used for each of these types of visits could be quite different. Alternately, a doctor could choose to have a single virtual care template to account for the most complex type of virtual visit they would provide and accept that a less involved encounter (e.g., a virtual check-in) would leave many areas of that template blank.

Regardless of the path chosen for templates, the fundamentals of documenting virtual care are similar to in-office care. The medical record should answer the following questions:

• Why is the visit taking place?
• What was performed?
• What is the management plan?

It is also a good idea to add a few other details that could come into play with final code selection:

• Who initiated the discussion?
• What communication method was used?
• How much time was spent in communication?
• Was informed consent obtained?

Signature of the responsible clinician is always a good practice. Remember that as the clinician, you are free to construct your medical record in the manner that makes the most sense to you within the context of patient care.

Remote Image/Video Evaluation

Remote Image/Video Evaluation is when a doctor provides an opinion on an image or video submitted by an established patient. The image submitted by the patient can be saved in Documents/Images. Responding within 24 hours is required so documentation of that fact is very important.

Virtual Check-in

Virtual Check-in is when a doctor communicates directly with a patient to accomplish what would have otherwise required an office visit. Live communication is required so notation of that fact is very important.

E-Visit

An E-Visit is when a doctor and patient engage in discussion through an online patient portal like RevolutionPHR. Code levels vary based on time so notation of time spent is very important.

Telephone Services

Telephone Services are when a doctor and patient communicate via telephone as a replacement for an office visit. Code levels vary based on cumulative time spent in discussion so notation of that detail is very important.

Telehealth Visit

Telehealth encompasses types of visits that would generally take place in person but are taking place using audio/video telecommunication technology. As such, a physical exam will commonly occur. The associated encounter template could, therefore, be very similar to one used for in-office visits.

Alternately, it could be pared back to just those elements of the physical exam that the clinician would expect to evaluate by the technology employed by the practice. For example, if the intent was to use FaceTime as the communication method without any other equipment, the clinician could remove any form of internal ocular health assessment from the associated encounter template.

Irrespective of template setup, the documentation included should highlight the audio-visual system used and make it clear that live interaction took place.

Interprofessional Internet/Telephone Consultations

Interprofessional Internet/Telephone Consultations cover scenarios where one doctor requests the opinion of a consultant without a visit being scheduled. Code levels vary based on time so notation of time spent is very important.