A strong telehealth note should capture not just the clinical work, but the context of the visit. For telehealth E/M services, three simple details can make a meaningful difference for billing and compliance: how the visit happened, where the patient was, and whether the patient or guardian agreed to receive care via telehealth.
1. Modality: Document How the Service Was Delivered
Start by documenting the telehealth modality. CMS defines Medicare telehealth largely by the communication method used. Under 42 CFR 410.78, this usually means real-time audio and video. CMS also allows some services to be furnished audio-only when the clinician can use video but the patient cannot or does not consent to video.
Important points to note:
- Document whether the visit was audio-video or audio-only.
- If audio-only is used, clearly state why video was not used.
2. Patient Location: Document Where the Patient Was During the Visit
Next, document where the patient was during the visit. CMS defines the originating site as the patient’s location at the time the telehealth service occurs. This detail can affect billing and helps support the place of service reported, including whether the patient was seen in their home or another setting.
- Document the patient’s physical location (e.g., home, work, or school).
- Include the provider’s location if required by your workflow or payer policy.
3. Patient or Guardian Consent: Document Agreement to Receive Telehealth Services
Finally, document consent. HHS telehealth guidance explains that informed consent requirements can vary by law and payer, and that verbal consent may be documented in the record. For pediatric visits, the note should reflect parent or legal guardian consent when required. The record should show that the patient or guardian understood the telehealth format and agreed to proceed.
Specifically:
- Document the patient’s consent to telehealth.
- For minors, document parent or guardian consent when applicable.
- If others are present, note that the patient or guardian agreed to proceed.
Why It Matters
These three details are easy to miss, but they matter. Clear documentation of modality, patient location, and consent helps support cleaner claims, fewer denials, and a record that better reflects how care was actually delivered. These details should complement, not replace, standard E/M documentation requirements such as medical necessity, history and examination (as applicable), and medical decision-making or time.
Key Regulatory and Government Sources
- Centers for Medicare & Medicaid Services (CMS), Telehealth
- 42 CFR § 410.78 Telehealth Services
- CMS Medicare Learning Network, Telehealth & Remote Patient Monitoring booklet
- Telehealth.HHS.gov (Obtaining informed consent)
Because telehealth coverage rules can vary by payer and state, organizations should confirm any additional documentation requirements beyond CMS, including state consent laws, Medicaid rules, and commercial payer policies.
