Compliance: Want to Get More Specific With Your Telehealth Documentation? Here’s How.

Why This Topic Matters

Telehealth documentation can be scrutinized in audits, and incomplete notes may fail to show what kind of encounter occurred or how it should be supported. This article helps readers understand the broad documentation areas that should be reviewed for telehealth compliance.

Article Sections

1. Audio-Only Visits

   This section discusses documentation considerations for telephone-based telehealth encounters and the kinds of information that should be captured in the record. It focuses on general compliance and audit readiness for this visit type.

2. Audio and Video Visits

   This section covers documentation considerations for live audiovisual telehealth encounters and the broader elements that may need to appear in the note. It also references general guidance from CMS and the importance of payer-specific review.