The regulatory landscape surrounding telehealth has undergone numerous changes over the past several years. Temporary flexibilities granted during the federal Public Health Emergency (PHE) created new opportunities for patient access, but also introduced documentation challenges that continue to surface during audits and compliance reviews.
Commonly Missed Documentation Elements
Modality of Service
Coding professionals sometimes encounter conflicting documentation regarding modality of a visit. For instance, one portion of the record may indicate a video visit, while another references a telephone encounter. These discrepancies create uncertainty regarding code selection, modifier assignment, and reimbursement eligibility. Medical records should clearly specify whether the service was provided using audio-video technology or audio-only communication, when permitted. Additionally, when technical disruptions occur, documentation should reflect the nature of the issue, any shift in modality (e.g., video to audio-only) and any impact on care delivery.
Patient and Provider Location
Although requirements vary among payers and settings, documentation should clearly identify the patient’s location and the provider’s location during the telehealth encounter, when applicable. This information may support compliance with federal and state telehealth requirements, and assists organizations in validating that services were rendered appropriately. Time should also be clearly documented if basing the level on that metric.
Patient Consent
Patient consent is another area that can create documentation challenges, particularly when organizations rely on templates that assume consent was obtained without specifically documenting it. Auditors frequently evaluate whether documentation adequately demonstrates that the patient agreed to receive services via telehealth. There should be clear evidence that the patient agreed to telehealth services, and organizations should verify that workflows consistently capture and retain consent documentation in accordance with Centers for Medicare & Medicaid Services (CMS) guidance, state law, payer requirements, and organizational policies.
Documentation Standards Do Not Change
Telehealth does not lower documentation standards. Documentation should support the same level of medical necessity expected during an in-person encounter. Auditors continue to evaluate whether the history, assessment, medical decision-making, and treatment plan support the reported service level. Simply stating that a visit occurred via telehealth does not establish medical necessity.
Template Overuse and Cloned Documentation
Many telehealth platforms automatically populate statements regarding technology, consent, and other encounter details. Auditors are increasingly looking for evidence that documentation was individualized to the patient and encounter. While templates can improve efficiency, organizations should verify that automatically generated language accurately reflects what occurred during the encounter.
Fragmented Documentation Across Systems
Another risk area is documentation distributed across multiple platforms; in other words, portions of the telehealth record reside within a telehealth platform, while the clinical note resides within the organization’s electronic health record (EHR). If coders and other professionals cannot access all components of the record, organizations risk inaccurate coding, incomplete audits, and gaps in documentation integrity.
This also raises compliance concerns related to the Designated Record Set (DRS), as telehealth platform documentation may be considered part of the DRS, depending on how the organization defines and operationalizes its DRS policy.
Organizations should evaluate whether coding, billing, compliance, and audit personnel have appropriate access to all systems containing telehealth documentation, and ensure that telehealth platforms are explicitly addressed in the organization’s DRS policy.
Audit and Enforcement Trends
Recent enforcement activity from CMS, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG), and the U.S. Department of Justice (DOJ) continues to focus on telehealth arrangements that lack sufficient documentation, fail to support medical necessity, or involve services that were not properly rendered. While many enforcement cases involve allegations of fraud schemes, they also reinforce an important lesson: documentation remains the primary evidence that a service occurred as reported.
By strengthening documentation practices, improving system access, and maintaining focused audit oversight, organizations can better navigate the evolving telehealth compliance environment.
