When you see a patient for a telehealth visit, you should document the visit at the same level as an in-person visit, reflecting exactly what was done during the visit. This helps ensure accurate claims and billing processes. It's also important to document that you performed the visit through audio-video telecommunications.
As explained in the UnitedHealthcare Care Provider Administrative Guide for Commercial and Medicare Advantage, we have the right to assess health care provider records to determine the accuracy of CPT® coding. You can find information about our requirements related to medical records in chapter 12.
View the UnitedHealthcare Telehealth policy and the Evaluation and Management policy for more information.