The Rise of Telehealth Services Has Been Nothing Short of Sudden.

The Rise of Telehealth Services Has Been Nothing Short of Sudden.

Initially seen as a temporary solution in response to the pandemic, telehealth has proven its value and is clearly here to stay. But with this new mode of healthcare delivery comes a slew of challenges, especially for our coding professionals.

When it comes to coding for telehealth, there are key differences compared to traditional in-person visits. First, there’s the matter of service type. Telehealth can range from real-time audio-visual consultations to asynchronous “store-and-forward” methods. Each of these service types has its own set of specific codes, and the guidelines for their usage are continually evolving. This means coders must stay updated, now more than ever, to ensure they’re capturing services accurately.

But the nuances don’t stop there.

The location of the patient during a telehealth service – be it at their home, a nursing facility, or in an outpatient setting – can affect coding. The Centers for Medicare & Medicaid Services (CMS) and other payers have specific place-of-service codes for telehealth to distinguish these services from traditional ones. Mistakes in these codes can result in claim denials or compliance issues.

Documentation is another critical aspect. Physicians and providers have adapted their practices for virtual care but ensuring that documentation captures the full scope and quality of the care provided is vital. The specifics of patient consent for virtual services, the technology used, and even the reason for a virtual visit over an in-person one should be documented meticulously. This doesn’t just protect providers in terms of compliance; it also ensures that the care being delivered via telehealth is of the highest standard.

Now, what about the future?

As we look ahead, it’s evident the telehealth boom isn’t a passing trend. Its convenience, effectiveness, and adaptability mean that virtual care will likely grow even more integral to our healthcare landscape. This signifies that the coding community should anticipate more updates, guidelines, and possibly even new codes tailored for telehealth.

In conclusion, while telehealth has provided an invaluable platform for continuing patient care during these challenging times, it also brings along intricate coding and documentation challenges. It’s imperative for coding professionals to be proactive, stay educated, and collaborate closely with providers to ensure telehealth services are captured accurately and compliantly. As we navigate this ‘new normal’, let’s embrace the changes, rise to the challenges, and ensure that telehealth is coded just as effectively as traditional care.

Let’s keep the conversation going and together, navigate the exciting realm of telehealth coding and documentation!

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Angela Comfort, MBA, RHIA, CDIP, CCS, CCS-P

Angela Comfort currently is a senior consultant for e4 Services and CDI Transformational Leader at Montefiore Health System. She is known to inspire and motivate individual and facility progress.

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