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Best practices for clinical and telehealth documentation during COVID-19

By Hamilton Lempert, MD, TeamHealth Chief Medical Officer, Coding Policy

The healthcare community continues to learn new information about COVID-19 and its impacts, making the important role of clinical documentation as valuable as ever.

As always, to bill for the clinical services provided, clinicians must perform and document a History, Physical Exam and Medical Decision-Making in the patient record. Even if the patient is isolated and the clinical team must use technology to communicate, the clinician must still perform and sufficiently document items in accordance with the requirements for billing each level of service.

Documentation is necessary for all the same reasons as before COVID-19, such as communicating to other healthcare providers about a patient’s condition at the time they were seen. Similarly, documentation is important during the COVID-19 public health emergency for many reasons, including:

  • The United States government and many payers have agreed to waive the patient responsibility for certain patient costs related to COVID-19 evaluation, testing and/or treatment. Clinicians must properly document their services so the patient won’t be held responsible for costs that the government and insurance companies have agreed to pay.
  • Clinical documentation supports the proper ICD-10 coding, which clarifies the patients who have COVID-19, who are suspected of COVID-19 and who do not have COVID-19. This information is important in creating the government’s public policy and the local policies at healthcare facilities.

For more information on COVID-19 documentation, see the attached guidance:

If you are interested in more information TeamHealth is offering related to COVID-19, access our COVID-19 channel on Zenith, TeamHealth’s mobile communication application. There is a special page devoted to general and telemedicine documentation issues.