Training outlines telehealth documentation rules for new providers

During a recent training session on CCS Note & Policy for providers in Ashland County, Wisconsin, key guidelines for telehealth documentation were highlighted, emphasizing the importance of compliance with HIPAA regulations. The session, held on June 3, 2025, focused on the distinctions between billable and non-billable services, particularly in the context of telehealth.

A crucial takeaway from the meeting was the requirement for providers to include specific details in their progress notes when conducting telehealth sessions. Providers must document two critical assessments: one regarding the client's demeanor and engagement, and another about their surroundings, including any individuals present during the session. For instance, a provider might note, "George and I met via telehealth; he was alert and engaged throughout," alongside details about his mother being present in the room.

The training also stressed the necessity for new providers to familiarize themselves with the telehealth policy and to sign a telehealth provider agreement, indicating their willingness to offer telehealth services. This agreement is essential for ensuring that all providers are aligned with the established protocols.

Overall, the meeting underscored the importance of thorough documentation in telehealth practices, ensuring that providers are equipped to meet both legal and professional standards. As telehealth continues to grow, adherence to these guidelines will be vital for maintaining quality care and compliance.