Most of us have sorted out about whether we’ll offer some or all of our psychotherapy services through a telehealth platform. We’re more aware that essentially all insurance companies will cover the service now – with varying degrees of approval before using it. We also know that not all video platforms are HIPAA compliant, so we want to make sure we’re using a platform that is appropriate for use.
Working with my consulting clients, one thing I have noticed is that not everyone is clear about how to document the use of telehealth in progress notes.
Telehealth is not considered a unique service – it is a modality of service. So, most of the rules related to regular progress note documentation stand for services rendered electronically. In nearly all circumstances the services are rendered live and face-to-face.
One important thing to remember, especially if these services will be paid for by insurance, is that the note needs to specifically document that the service was rendered over telehealth, including the specific telehealth platform that was utilized for the service. The absence of both of these pieces of information could lead to an insurance retraction during an SIU review.
So, if you’re not documenting this information on your telehealth progress notes – you may want to start.