Telehealth Documentation Guide 2026
The complete guide to documenting virtual visits. Master telehealth-specific requirements, billing codes, state regulations, and best practices for compliant, thorough documentation.
Includes CPT codes, consent templates, exam documentation tips, and real note examples.
Telehealth Documentation in 2026
Telehealth Documentation Requirements
Essential elements that must be documented for every telehealth visit beyond standard clinical notes.
Patient Identification & Consent
RequiredRequired Elements:
- Patient full name and date of birth
- Physical location of patient at time of visit
- Provider location at time of visit
- Verification of patient identity (visual confirmation)
- Documented informed consent for telehealth
- Patient agreement to telehealth limitations
Pro Tip
Document patient location at start of every visit - it affects licensure, prescribing, and billing.
Technology & Platform Documentation
RequiredRequired Elements:
- Platform/technology used (e.g., Zoom for Healthcare, Doxy.me)
- Audio and video quality assessment
- Any technical difficulties encountered
- Whether visit was synchronous (live) or asynchronous
- Encryption and HIPAA compliance statement
- Backup communication plan if disconnected
Pro Tip
Note any connectivity issues that may have affected examination or communication quality.
Clinical Examination Documentation
RequiredRequired Elements:
- Chief complaint and HPI
- Review of systems (adapted for telehealth)
- Physical examination findings (visual observations)
- Limitations of remote examination noted
- Patient-reported vitals if obtained
- Any in-person components recommended
Pro Tip
Document what you CAN observe rather than leaving exam blank. Note limitations explicitly.
Assessment & Plan
RequiredRequired Elements:
- Clinical assessment/diagnosis
- Treatment plan including prescriptions
- Follow-up recommendations (telehealth vs in-person)
- When in-person visit is medically necessary
- Patient education provided
- Emergency instructions given
Pro Tip
Specify whether follow-up can be telehealth or requires in-person examination.
Billing & Compliance Elements
RequiredRequired Elements:
- Time spent (start and end time)
- CPT/billing codes with telehealth modifiers
- Place of service code
- Medical necessity statement
- Provider credentials and license state
- Attestation that services rendered
Pro Tip
Document time carefully - many telehealth codes are time-based.
Telehealth CPT Codes & Billing
Common billing codes for telehealth services in 2026. Always verify with specific payers.
| CPT Code | Description | Modifier | POS | Notes |
|---|---|---|---|---|
| 99211-99215 | Established patient office visits | 95 or GT | 02 (Telehealth) or 10 (Home) | Most common telehealth codes. Use modifier 95 for synchronous audio-video. |
| 99201-99205 | New patient office visits | 95 or GT | 02 or 10 | New patient telehealth visits. Some payers restrict new patient telehealth. |
| 99421-99423 | Online digital E/M (async) | None required | 02 | For patient-initiated digital communications over 7-day period. |
| 99441-99443 | Telephone E/M services | None required | 02 | Audio-only visits. 5-10, 11-20, or 21-30 minute increments. |
| 90832-90838 | Psychotherapy services | 95 | 02 or 10 | 30, 45, or 60 minute psychotherapy. Widely covered for telehealth. |
| G2012 | Virtual check-in (brief) | None | 02 | Brief communication to determine if office visit needed. 5-10 minutes. |
| G2010 | Remote evaluation of images | None | 02 | Patient-submitted photos/videos for evaluation. Store-and-forward. |
| 98966-98968 | Non-physician telephone services | None | 02 | For qualified healthcare professionals (not physicians). 5-10, 11-20, 21-30 min. |
Important Billing Notes
- • Modifier 95 is preferred for most payers; GT may be required by some
- • Place of Service 02 = telehealth facility; 10 = patient home
- • Some payers require specific originating site requirements
- • Always document time for time-based codes
Physical Examination via Telehealth
What you can assess remotely and how to document examination limitations appropriately.
General Appearance
Can Assess:
- ✓Level of distress
- ✓Hygiene and grooming
- ✓Body habitus
- ✓Alertness and orientation
- ✓Speech quality and rate
- ✓Affect and mood
Limitations:
Cannot assess body odor, subtle findings
Tip: Good lighting essential; ask patient to position camera appropriately
Skin
Can Assess:
- ✓Visible rashes or lesions
- ✓Color changes (cyanosis, jaundice)
- ✓Wounds visible on camera
- ✓Swelling or edema
Limitations:
Texture, temperature, subtle lesions difficult; dependent on camera quality
Tip: Ask patient to use phone camera for close-ups of skin concerns
Head/Eyes
Can Assess:
- ✓Pupil size and symmetry (if good lighting)
- ✓Scleral color
- ✓Eyelid abnormalities
- ✓Facial symmetry
- ✓Obvious deformities
Limitations:
Cannot perform fundoscopic exam, accurate pupil reactivity
Tip: Ask patient to shine phone flashlight near eye for pupil assessment
Musculoskeletal
Can Assess:
- ✓Range of motion (patient demonstration)
- ✓Gait observation
- ✓Visible swelling or deformity
- ✓Posture assessment
- ✓Functional movements
Limitations:
Cannot palpate, assess strength against resistance accurately
Tip: Have patient perform specific movements; observe for pain responses
Respiratory
Can Assess:
- ✓Respiratory rate (count visually)
- ✓Use of accessory muscles
- ✓Speaking in full sentences
- ✓Audible wheezing/stridor
- ✓Cough characteristics
Limitations:
Cannot auscultate lungs without remote stethoscope
Tip: Ask patient to take deep breaths; note any visible distress
Mental Status
Can Assess:
- ✓Orientation x3
- ✓Attention and concentration
- ✓Memory (immediate, recent)
- ✓Language and speech
- ✓Mood and affect
- ✓Thought process and content
Limitations:
Some standardized tests need in-person; subtle deficits harder to detect
Tip: Mental status exam often most complete component of telehealth visit
Complete Telehealth Note Example
A well-documented telehealth visit note demonstrating all required elements.
Follow-up Hypertension Management - Telehealth
62-year-old male
Subjective
Objective
Assessment
Plan
State Telehealth Regulations (2026)
Key requirements vary by state. Always verify current regulations as they change frequently.
| State | Licensure | Controlled Rx | Consent | Payment Parity |
|---|---|---|---|---|
| California | Must be licensed in CA; limited exceptions for consultations | Controlled substances require in-person or telehealth with video | Verbal consent sufficient; written recommended | Full payment parity law for commercial insurers |
| Texas | TX license required; telemedicine license available | Controlled substances permitted via telehealth with certain conditions | Written or verbal consent required before first telehealth visit | Payment parity for commercial (with some exceptions) |
| New York | NY license required; limited interstate exceptions | Controlled substances via telehealth permitted for established patients | Informed consent required and documented | Full telehealth parity law enacted |
| Florida | FL license required; no special telehealth registration | Controlled substances restricted; Schedule II requires in-person | Written consent required prior to telehealth services | Partial parity; Medicaid has restrictions |
| Illinois | IL license required; consulting exceptions exist | Controlled substances via telehealth permitted with conditions | Informed consent required | Payment parity for commercial insurers |
* Regulations change frequently. Verify current requirements with your state medical board and relevant payers.
Telehealth Informed Consent Elements
Required and recommended elements for telehealth consent documentation.
Nature of Telehealth
RequiredExplanation that care will be delivered via electronic communication
Benefits
RequiredConvenience, reduced travel, access to specialists, etc.
Risks & Limitations
RequiredTechnology failures, limited physical examination, potential misdiagnosis
Privacy & Security
RequiredHow PHI is protected, encryption used, recording policies
Right to Withdraw
RequiredPatient can stop telehealth visit and request in-person care
Emergency Protocols
RequiredWhat to do if emergency arises during or after visit
Patient Location
RequiredPatient must disclose physical location at time of each visit
Billing Information
How telehealth visits are billed and potential patient costs
Recording Consent
Whether visit may be recorded for documentation/quality
Common Telehealth Documentation Mistakes
Avoid these frequent errors that can lead to compliance issues and claim denials.
Failing to document patient location
Consequence: Licensure violations, billing issues, prescribing non-compliance
Solution: Document patient physical location (city, state) at start of every visit
Not noting telehealth-specific consent
Consequence: Legal liability, compliance issues
Solution: Reference signed consent or document verbal consent each visit
Leaving physical exam blank
Consequence: Appears incomplete, may affect billing
Solution: Document what you CAN observe and explicitly note limitations
Using wrong place of service code
Consequence: Claim denials, reduced reimbursement
Solution: Use POS 02 for telehealth facility, 10 for patient home
Forgetting to document time
Consequence: Cannot bill time-based codes, audit risk
Solution: Record start/end time and total time for every telehealth visit
Not documenting technology used
Consequence: Compliance gaps, cannot verify HIPAA compliance
Solution: Name the platform and note it is HIPAA-compliant
Omitting audio/video quality notes
Consequence: Cannot explain exam limitations if questioned
Solution: Document quality as good/fair/poor and any disruptions
Inappropriate prescribing documentation
Consequence: DEA violations, licensing board complaints
Solution: Know state rules for controlled substance telehealth prescribing
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Frequently Asked Questions
Common questions about telehealth documentation answered.
What documentation is required for telehealth visits?
Telehealth documentation requires all elements of an in-person visit PLUS: patient location at time of visit, provider location, technology platform used, verification of patient identity, documented informed consent, any technical difficulties, and explicit notation of examination limitations. Time documentation is especially important for telehealth billing.
Do I need written consent for telehealth visits?
Requirements vary by state. Some states accept verbal consent if documented in the medical record, while others require written consent. Best practice is to obtain written informed consent at the first telehealth visit, then document verbal reconfirmation at subsequent visits. Always check your state regulations.
What CPT codes do I use for telehealth visits?
For synchronous video visits, use standard E/M codes (99211-99215 for established, 99201-99205 for new patients) with modifier 95 or GT. Place of service is typically 02 (telehealth) or 10 (patient home). For audio-only, use 99441-99443. Always verify with the specific payer as coverage varies.
Can I prescribe controlled substances via telehealth?
Generally yes, though rules vary by state and are evolving. The DEA's COVID-era flexibilities for Schedule II-V prescribing have been extended. Most states now permit controlled substance prescribing via telehealth for established patients. New patient prescribing may have additional requirements. Always verify current state and DEA regulations.
How do I document the physical exam for telehealth?
Document what you CAN observe: general appearance, visible skin, respiratory rate, affect, speech, visible swelling, range of motion, gait. Explicitly note limitations: "Unable to auscultate lungs via telehealth." Patient-reported vitals should be labeled as such. Never leave the exam section blank.
What if the technology fails during a telehealth visit?
Document the technology failure, what troubleshooting was attempted, and whether the visit was completed via alternative means (phone) or rescheduled. If completed via phone, use appropriate audio-only codes. Document any clinical limitations resulting from the technology issues.
Do telehealth visits get reimbursed the same as in-person?
Many states have telehealth parity laws requiring equal reimbursement for commercial insurance. Medicare generally reimburses telehealth at in-person rates for many services. However, some payers still have lower telehealth rates, and audio-only visits typically reimburse less than video visits. Check specific payer policies.
Can AI help with telehealth documentation?
Yes, AI documentation tools like PatientNotes are particularly valuable for telehealth because they capture the conversation accurately, ensure all required telehealth elements are documented, and reduce the administrative burden. The AI can prompt for telehealth-specific elements like patient location and technology notes.
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