Documentation

This page is intended to be a resource for our provider network to find answers to critical questions during the COVID-19 crisis. As we receive more information, Community Care will be updating the site, so check back frequently for the most up-to-date information.  As new questions are added, they will appear at the top of the list.

How specific do providers have to be related to the mode of delivery of the services (whether via telehealth or telephone)?

Community Care expects the type of service documentation to be as specific as possible (i.e. encrypted video, Skype, telephone).

Do we need to institute a policy due to conflicts between telehealth permitted-activities and current policy (e.g., Quality of Service)?

Community Care requires the use of the attestation process designated by DHS. Please refer to your internal risk management and Policies and Procedures to reconcile conflicting policies.

Is it acceptable to provide services without obtaining required signatures (consent for treatment, encounters, treatment planning)?

Yes. While completion of these documents is required, when not possible to get, the clinical record should clearly note the reason why the signature was not able to be obtained. Providers should establish a policy detailing how member signatures will be obtained at a later date.

How do providers document encounters when providing services via Telehealth or telephone?

Document a progress note for each service delivered that includes indication that the service was provided via Telehealth, type of device used, location from which the service is delivered and location of the member. Continue to assure that the note is fully dated, signed by the service provider and contains the actual service clock start and stop times. Encounter form signatures may be marked ‘signature exempt – Telehealth' with a provider policy to obtain signatures as soon as possible after the COVID-19 crisis has passed.

Would Telehealth or telephone services count towards treatment days in the count towards treatment plan due dates?

Yes. Treatment planning and routine reviews should continue using Telehealth/telephonic delivery methods. Treatment plan updates should be clearly noted, including a statement that the review occurred, member provided verbal consent and the reason why signatures were not able to be obtained. Clearly document the planning process in the member’s record and develop a policy and procedure to obtain signatures at a later date, once the risk has passed.

Does Telehealth require a written order, or need to be in the client's treatment plan?

A written order is not required. The treatment plan or progress note should document the inclusion of Telehealth as the method of service delivery due to the COVID-19 crisis.

How do you recommend/how long do we have to safely acquire peers' signatures on progress notes and other CPS documentation?

Whenever it is possible to safely do so, given social distancing and CDC recommendations. Otherwise, the medical record documentation should include the reason that the signature was not obtained. Provider contingency plans should be in place to obtain signatures at a later date.

How do you want us to document signature exempt at this point for all Telehealth? Do we need to state something in signature space, or we can just have service location 02?

On encounter forms, providers should note “signature exception-Telehealth” for each Telehealth service provided. Place of service ‘02’ should be used on the claims form. Providers should develop a policy detailing how they will obtain signatures at a later date.

How should Telehealth be documented in the chart, as some clients are still coming into the office?

It is acceptable to deliver both office-based and Telehealth modes. Document a progress note for each service delivered that includes the service location (Office, Telehealth or telephonic), type of service delivered, location from which the service is delivered and location of the member. Continue to assure that the note is fully dated, signed by the service provider and contains the service actual clock start and stop times.

How do providers obtain consent from members when using telehealth services?

The consent to treatment document should include that Telehealth will be provided during the COVID-19 crisis, identity those who will provide Telehealth services and that third-party applications like Skype or Facetime potentially introduce privacy risks. Members may choose telephonic services only. Alternately, obtain verbal consent and make a note to this effect in the member’s medical record and plan to obtain the member’s written consent, as soon as possible when the risk has passed.

Do we need to note if the service was provided via phone or video?

Yes. Please specify the mode of delivery in the clinical documentation.