AthenaTelehealth Training Information

November 2024 

Billing Compliance when using AI technology 

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Many of us have been using AI technology (Abridge) to assist with our notes, which has been a great help, in my opinion. While the technology seems to capture our visits accurately and in language a patient can understand, we still need to make sure the language in the notes meets certain criteria for billing and compliance. Specifically, we need to ensure the language in the note supports the billing codes we choose and also meets the criteria for the visit type, for example a Medicare Wellness or a TCMS visit. For this reason, we should still use and refer to the various Encounter Plans and Macros that have been developed. We also may need to edit the AI output or carefully articulate certain language in the visit such as “At goal” or “controlled.”  

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Meeting Billing Requirements 

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1. Chronic Conditions: 

          a. Remember that the goals need to be in the note, and whether the patient is “at goal” or “not at                         goal”   or “controlled” or “uncontrolled”. 

          b. Articulate this language in the visit so it is included. Please check that the AI output has this                               language in the A&P. Edit the language in the A&P if it is not included.  

         c. Include the goals, using the macro’s and EP templates makes it easy. Ex. BP goal is less than                             130/80.  

   2. Medicare Wellness Visit 

         a. There are many requirements here, so while you can still use the AI in the background, please use                   the template and work your way through the template for this.  

                    i. You can supplement the note with the AI. I find it helpful to pick up on the specifics that are                                discussed and chronic conditions or new concerns that are brought up.  

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Documenting Consent 

1. You absolutely need patient consent in the encounter note if you are using AI technology. Please use the macro “AIConsent” to document this.  

Julianne Tauscher, DNP