Expanded Telemedicine Regulations: Documentation Requirements Overview

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By Doreen DeGroff | Apr 3, 2020

2 minute read EHR/EMR| Blog

With the expansion of the telemedicine guidelines and payment criteria, facilities are quickly expanding or rolling out solutions to meet the anticipated demand as well as many vendors and suppliers are offering options to health systems to enable this functionality.

While telemedicine is critical in this crisis to provide much needed care, it is easy to fall into reactive mode and falter in providing solid communication regarding technology changes and documentation required for each type of visit.

Legislation and patient flow is changing daily, and strong governance and change management is more critical than ever. On March 30th, 2020, the Centers for Medicare and Medicaid Services (CMS) released an array of temporary regulatory waivers to provide flexibility for healthcare providers to respond to the coronavirus pandemic.  This includes expanding telehealth coverage until the current expiration date of January 2021. Guidelines still apply to telehealth visits and sites need to ensure they are practicing within them and are able to recognize revenue properly. Here, we have summarized a few highlights on documentation when providing telemedicine visits:

  • Telemedicine regulations are still a work in progress. It is more critical than ever to define your approach and handle these type encounters just as you would any patient care visit as well as evaluate on a regular basis what is working and what is not.
  • The virtual visit is a patient visit. Normal documentation is still necessary and required.
  • Be sure your staff and providers understand the current requirements, the time requirement for the visit, and record the amount of time spent on the visit so that proper billing can take place. This may mean adding custom fields to the system or documentation to capture this information. As of the writing of this article, these requirements are:

Telehealth Visit:

  • Established patients only, although audits are relaxed at this time.
  • Needs to be patient initiated and verbal consent and documentation is required to bill.
  • Physician or other qualified health care professionals.
  • Evaluation, assessment and management of the patient.
  • Use only once per seven day period. See CPT book for further details regarding when the seven days begin, how to count time, and which “qualified non-physician health professionals” it applies to, as well as other documentation requirements.
  • Service time must be more than 5 minutes.
  • Cannot be used in conjunction with other Evaluation and Management (E&M) services.

Virtual Check-In:

  • Established patients only, although audits are relaxed at this time.
  • Must be clinician who can bill E&M services.
  • No geographic restrictions.
  • Needs to be patient-initiated and verbal consent and documentation is required to bill.
  • 5 minute minimum required.


  • Established patients only, although audits are relaxed at this time.
  • Telephone or on-line visits via portal.
  • Physician or other qualified health care professionals.
  • 5 minute minimum.

Remote Monitoring:

  • Monitor of physiologic parameters (e.g: weight, blood pressure, pulse oximetry etc.).
  • Physician, qualified health care professionals or clinical staff depending on code used.
  • Must be monitored for more than 16 days.
  1. Educate your staff so they understand telemedicine options, even staff who may not be directly involved so that the same message is being communicated by all.
  2. Take the time to educate your patients. This is new to most of them and they need to understand the process in regards to protecting their information.
  3. Clearly document your approval process. This may mean adding fields to the EHR to record this information. However, this will not only assist in providing the accurate information to your patients and guide your providers, but help you should you need to refer back for billing clarification, etc.

References for set-up considerations

The pressure is on to reduce the spread of the virus and provide virtual options for care. While considering your options, here are some references that can help you understand what to consider:

AHIMA Special Update: Telehealth and Relaxed HIPAA Enforcement During COVID-19

Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency

CMS General Provider Telemedicine Toolkit

ACP COVID-19 Telehealth Coding and Billing Practice Management Tips

CMS Moves to Allow Digital Communications by PTs

Special Coding Advice during COVID-19 Public Health Emergency

CDC Guidance:


If we can help you enabling Health IT for your facility in the battle against coronavirus, please don’t hesitate to connect with us.

About the Author:
Doreen DeGroff

MEDITECH Senior Product Director, CereCore

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