Documentation FAQs for Virtual Care
1. Are there elements I should be documenting for a telehealth visit that I don’t typically document for an in-person visit regardless of state or payor?
Yes. A therapist should document the following:
- The need for a telehealth visit (e.g. “Patient opting for telehealth visit to reduce risk of COVID-19 infection acquisition and transmission.
- Therapy was provided via telehealth
- If the telehealth documentation platform used does not already indicate this, a therapist should document the originating and distant site. The originating site is defined as the site of the patient’s physical location at the time services was furnished. The distant site is the physical location where the provider delivering the service is.
- The names of all persons participating in the telehealth service and their role in the encounter.
- If the telehealth documentation platform does not already indicate this, the mode of service transmission (e.g. digital conference)
2. What documentation requirements does my state require for telehealth physical therapy?
Aside from what is listed above, the states that Alliance currently has a presence in do not have additional documentation requirements different from an in-person visit.
3. How should I document objective information during a telehealth PT evaluation?
For measurements such as ROM, consider using degree, or percentage estimates are. If degree estimates are used, consider using measurements in multiples of 5, e.g. 30°, 45, 90°, 120°, etc.
For strength measurements, consider using descriptions of functional movements, for example:
- “Pt. must use bilateral UE assistance to safely rise from a chair with hips and knees at 90 degrees.”
- “Pt. cannot lift a gallon of milk to shoulder level or higher with the L UE.”
For palpation, ask the patient to perform on themselves or with the assistance of a family member or caregiver and report level of tenderness and location.
For special tests, many will be able to be performed with proper verbal directions by the patient and others may be adapted that would otherwise be performed by the therapist in the clinic setting. Examples: Phalen’s, Tinel’s, Spurling's tests can easily to performed by the patient with proper verbal instructions.
Limitations include no Manual Muscle Testing (MMT), reflex testing and certain special tests will not be able to be modified to be safe and/or effective for the patient to perform on themselves.
4. How should I document objective data such as ROM for a progress report or a re-evaluation during a telerehab visit initially, or previously measured via goniometry?
Observational estimates as previously indicated. Make sure to indicate in your documentation the reason you are estimating these measurements. For example, “Progress note data captured via telerehab visit, PT unable to perform goniometry at this time.”
5. Which CPT codes can I charge during a PT Telehealth visit?
If a patient is paying out-of-pocket for a telehealth visit, a therapist can bill any appropriate code to cover the services provided. Since treatment is provided remotely, typical codes may include therapeutic exercise (97110), therapeutic activity (97530), neuromuscular reeducation (97112), gait training (97116).
However, if a patient is insured, the therapist should check with the individual responsible for verifying insurance benefits for their facility/location (I.e. local, or a corporate central insurance verification specialist) to determine which codes the insurance will cover for Telehealth.
This is important as some insurances, e.g., Cigna requires the use of 97110 regardless of the treatment rendered. So, for this insurance, if the objective of the treatment provided is specifically to improve functional performance, the therapist would bill 97110 rather than 97530.
Please refer to Quick Reference Guides for billing and CPT code restrictions on the Alliance intranet.
6. How long should a Telehealth visit last?
Clinically, this should be determined by the therapist based on the medical need of the patient. Typically, sessions last between 30 to 60 minutes. If the patient is insured, consideration should be given to any constraints the insurance may have.
7. During a telehealth visit, can I have a patient perform exercises using reps/duration etc.?
Yes, a patient can perform exercises that involve reps, sets, time, etc. Treatment should be based on the patient’s individual, medical needs, available equipment, and safety.
8. Can family members assist during a telehealth session?
Yes. As per the therapist’s clinical judgement, a family can assist with various tasks including palpation, home environment setup, patient transitions, etc.
9. Do the clinician and patient have to be in a private room during a telehealth session?
No, sessions do not necessarily need to be conducted in a private room, however, the clinician should make sure the space used appropriately maintains the privacy of the patient, and treatment can be delivered clearly, without distraction, and unnecessary interruption.