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. Signature requirements, including signed daily notes, signatures for service/treatment/ rehabilitation and other required plans and written consent, and encounter forms are suspended during the emergency declaration period. Verbal consent of the member must be documented for each service and for treatment planning per Provider Alert #26: Fraud, Waste, and Abuse (FWA) Updates to Documentation Signature Requirements During COVID-19, Revised 11/05/2020 (ccbh.com)

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

Each telehealth and/or office-based service requires a progress note to be recorded in the member’s medical record. The telehealth progress note must indicate that the service was provided via telehealth, as well as the type of device used (phone/video), location from which the service is delivered, location of the member and actual service clock start and stop times. Additional requirements are articulated in Provider Alert #12: FWA Activities During COVID-19, 2020 FWA Policy & Procedure Updates & Basic Documentation Required for Progress, Treatment, or Service Note (ccbh.com) and Provider Alert #26: Fraud, Waste, and Abuse (FWA) Updates to Documentation Signature Requirements During COVID-19, Revised 11/05/2020 (ccbh.com)

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. Providers are required to continue to obtain and document verbal consent in the medical record for every occurrence of a new or an updated plan. Documentation must reflect that the plan has been developed in collaboration with the member, and others as required, and the member’s agreement with the plan. Providers are strongly encouraged to obtain signatures electronically when possible. 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. Some treatment plan review periods have been extended by OMHSAS. More details can be found at OMHSAS COVID19 Provider Resources (pa.gov). Provider Alert #26: Fraud, Waste, and Abuse (FWA) Updates to Documentation Signature Requirements During COVID-19, Revised 11/05/2020 (ccbh.com)

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 encounter forms including signature exempt for all telehealth?

Encounter forms are not required for behavioral health services delivered through telehealth during the emergency declaration period. However, documentation must be included in the medical record that indicates the service was provided through telehealth and a signature could not be obtained for service verification purposes. This is in addition to noting in the medical record that the individual receiving services consented to receiving services through telehealth. When possible, an electronic signature should be obtained during the scheduled service. This also applies to drug & alcohol services funded through the Medical Assistance program. Provider Alert #26: Fraud, Waste, and Abuse (FWA) Updates to Documentation Signature Requirements During COVID-19, Revised 11/05/2020 (ccbh.com)

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?

Verbal consent to participate in telehealth services must be obtained from the member (parent/guardian for a child under 14 years of age) and documented in the medical record prior to service delivery. Initial verbal consent must reflect that the member has been informed of the equipment/technology used to provide the service and all persons who will be present at each end of the transmission and their role(s) in the service. Consent must also include documentation that the member has been informed of their ability to refuse services via telehealth and that such refusal will not be used as a basis to limit their access to other available services, alternatives to telehealth services and possible delays in service, need to travel, or risks associated with not having the services provided by telehealth. Documentation of verbal consent for each subsequent visit must include that the member consented to receiving services via telehealth per Provider Alert #26: Fraud, Waste, and Abuse (FWA) Updates to Documentation Signature Requirements During COVID-19, Revised 11/05/2020 (ccbh.com).

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.