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5 Must-Haves in Your Telehealth Documentation for 2025

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5 Must-Haves in Your Telehealth Documentation for 2025

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Telehealth documentation

Telehealth billing and coding requirements are changing in 2025, with many of the pandemic-era flexibilities that Medicare offered lifting as of January 1. If you want to continue collecting for the services that are still billable, you must ensure that your telehealth documentation is pristine.

Check these five essential features you must include in your telehealth documentation throughout 2025.

1. Patient Informed Consent

Nearly every payer you’ll be billing in 2025 has a requirement that you get consent from the patient before performing your services over telehealth. Once the patient provides consent, you’ll need to document that in their record, not just the first time you see them over telehealth, but every time.

2. The Patient’s Location

The documentation must include notation of where the patient is at the time of the telehealth visit. This will become increasingly important as some payers (including Medicare) require many patients to be at a healthcare facility during the visit rather than at home. But no matter what, you must document where the patient is at the time of the telehealth encounter.

3. The Provider’s Location

Your telehealth documentation must also clearly state where the provider is at the time of the visit. It could be taking place at the provider’s standard office location, their home, a temporary location or somewhere else, but an auditor should be able to find that information in the patient’s record if they ever review it, so ensure your provider includes it every time.

4. The Type of Equipment Used

You must indicate whether the visit was performed in real time (described as “synchronous”) or not (“asynchronous”), as well as the specific technology used to perform the televisit. Indicate not only the technology’s brand name, but also whether it was audio-video, remote monitoring, audio only, or something else.

5. The Total Time Spent

You should always document the total time spent on the telehealth encounter in your medical records. If possible, your telehealth documentation should also include start and stop times, since some payers do require that as well. It can not only satisfy compliance requirements, but may also make it easier for you to select the most accurate code for time-based services.

The time to prepare for how you’ll report telehealth in the new year is now. Let coding expert Toni Elhoms, CCS, CPC, CPMA, CRC, AHIMA-Approved ICD-10-CM/PCS Trainer show you the way during her exclusive online training, Master New 2025 Telehealth CPT Codes to Get Paid (98000 Series). Sign up today!

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