Virtual Care Documentation Best Practice

  • November 5, 2020

    With increasing reliance on virtual care, providers it’s important to be aware of the documentation requirements to comply with CMS standards. Virtual care documentation requirements are similar to a face-to-face encounter, but include four additional elements:

    1. Statement indicating the virtual care service was provided using both audio and video modalities
    2. Location of the patient and the provider
    3. Names of additional persons participating in the telemedicine visit and their role
    4. Statement indicating patient consent for the virtual care visit

    For more information and examples of best-in-class documentation, review this guide.

    Contact providerclinicalconsultants@premera.com if you have any questions.

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