CTC Documentation & Record Keeping 2 — Questions and Answers
Question 1: Which element is MOST critical to include in the telehealth visit note to distinguish it from an in-person encounter for billing purposes?
- Patient's insurance member ID
- Notation that the visit was conducted via telehealth and the technology platform used (Correct answer)
- Provider's DEA number
- Patient's preferred pharmacy
Correct answer: Notation that the visit was conducted via telehealth and the technology platform used
Telehealth visit notes must explicitly document that the service was delivered via telehealth and identify the platform to support accurate billing and audit defense.
Question 2: A patient sends a secure message to the clinic after a telehealth visit with follow-up questions. How should this communication be documented?
- It does not need to be documented unless the provider changes the treatment plan
- It should be saved only in a separate email folder
- It should be entered into the EHR as a patient communication with date, content summary, and provider response (Correct answer)
- It should be printed and filed in a paper chart
Correct answer: It should be entered into the EHR as a patient communication with date, content summary, and provider response
All patient communications, including secure messages, must be documented in the EHR to maintain a complete, auditable record of care.
Question 3: When a telehealth visit is terminated prematurely due to a technical failure, what should the provider document?
- Nothing, since no care was delivered
- The attempted visit, the nature of the technical failure, and any clinical actions taken before disconnection (Correct answer)
- Only the billing code for a failed visit
- The patient's refusal to continue the visit
Correct answer: The attempted visit, the nature of the technical failure, and any clinical actions taken before disconnection
Documenting a premature termination including the technical issue and any partial care provided protects the provider and ensures continuity of care.
Question 4: Under HIPAA, how long must a covered entity retain documentation of its policies and procedures related to telehealth?
- 1 year from the date of creation
- 3 years from the date of creation or last effective date
- 6 years from the date of creation or last effective date (Correct answer)
- 10 years from the date of creation
Correct answer: 6 years from the date of creation or last effective date
HIPAA requires covered entities to retain documentation of policies, procedures, and actions for 6 years from the date of creation or last effective date.
Question 5: A telehealth coordinator discovers that a clinician has been documenting patient encounters days after the visit with no addendum notation. What is the BEST corrective action?
- Delete the late entries and ask the provider to re-enter them with the correct date
- Educate the provider on late-entry documentation policies requiring a notation of the actual date of entry and reason for delay (Correct answer)
- Report the provider immediately to state licensing without internal review
- Accept the practice since electronic records automatically timestamp entries
Correct answer: Educate the provider on late-entry documentation policies requiring a notation of the actual date of entry and reason for delay
Late entries are permissible when properly flagged with the actual entry date and reason for delay, and providers should be trained on this standard.
Question 6: Which of the following best describes a 'consent to telehealth' document that should be retained in the patient record?
- A verbal agreement that the provider notes briefly in the chart
- A signed form acknowledging the patient understands the limitations, privacy risks, and technology requirements of telehealth services (Correct answer)
- A generic HIPAA authorization form
- A billing agreement form
Correct answer: A signed form acknowledging the patient understands the limitations, privacy risks, and technology requirements of telehealth services
A telehealth-specific informed consent document should outline service limitations, privacy considerations, and technology requirements and be retained in the patient's record.
Question 7: When documenting the location of a patient during a telehealth visit, why is capturing the patient's physical state or location important?
- It determines which CPT code is used for billing
- It establishes the jurisdiction whose laws govern the encounter and affects licensure and prescribing authority (Correct answer)
- It is required only for Medicare patients
- It allows the provider to schedule follow-up visits
Correct answer: It establishes the jurisdiction whose laws govern the encounter and affects licensure and prescribing authority
The patient's physical location during a telehealth visit determines the applicable state laws, including prescribing authority and licensure requirements for the provider.
CTC Documentation & Record Keeping 2
Which element is MOST critical to include in the telehealth visit note to distinguish it from an in-person encounter for billing purposes?