Telehealth Documentation Checklist: What Every Virtual Visit Note Needs in 2026

What should telehealth documentation include?

Quick answer: A complete telehealth note records five things: where the patient and clinician were, how they connected (video, audio-only or asynchronous), the patient's consent, what was examined remotely and what could not be, and billing details (place of service and modifier) that match the note. Get those right and most audit and denial risk goes away.

Telehealth is now a routine part of care, but the paperwork behind it is still where practices lose money. A visit can be clinically excellent and still fail an audit because the note never says the patient was at home, or never explains why the visit was audio-only.

This guide turns current 2026 rules into a checklist your clinicians can run through before they sign. It covers consent, location, modality, clinical content, coding, controlled substances and privacy.

What changed for telehealth in 2026?

Medicare's pandemic-era telehealth flexibilities are extended through December 31, 2027, and the DEA's controlled-substance prescribing flexibilities run through December 31, 2026. Both are temporary, so documentation should show which rule you relied on.

The Consolidated Appropriations Act, 2026, signed February 3, 2026, set the Medicare dates after the flexibilities briefly lapsed. The DEA's permanent special registration rule went to White House review in August 2026 but is not final yet. Check for updates before year-end.

Step 1: Document consent, identity and location before the visit

The first minute of a telehealth visit produces the facts auditors check most: who the patient is, where they are, and whether they agreed to virtual care.

• ☐Identity verified with two identifiers, or photo ID on camera for new patients
• ☐Patient location at the time of the visit, at least city and state
• ☐Clinician location, including home or clinic if your payer or state asks
• ☐Licensure: clinician licensed in the patient's state, or a compact privilege or exception noted
• ☐Informed consent recorded: verbal or written, the date, and who gave it
• ☐Consent scope: limits of a remote exam, privacy risks, cost-sharing, and the right to choose in-person care
• ☐Emergency plan: a callback number and the patient's address for emergency dispatch
• ☐Others present on either end, named with the patient's agreement
• ☐Interpreter name or ID, if one was used

Tip: Build these into a telehealth smart phrase or template so they are captured every time, not from memory.

Step 2: Record the modality and the clinical picture

A telehealth note must meet the same standard as an in-person note, plus a clear record of how the visit happened and what the remote format could not do.

How to document the modality

• ☐State the modality: real-time audio-video, audio-only, or asynchronous (store-and-forward, e-visit, portal message)
• ☐For audio-only visits, say why video was not used (no video access, patient declined, or connection failed) and that the patient agreed
• ☐Name the platform, which should be HIPAA-compliant and covered by a business associate agreement
• ☐Note technical problems, such as a switch from video to audio mid-visit
• ☐Record start and end times, or total time, for time-based codes

How to document the clinical content

• ☐History, and who supplied it (patient or caregiver)
• ☐Exam findings limited to what was observed, labeled as seen on video, for example "no respiratory distress on video; speaking full sentences"
• ☐Home-device readings (BP cuff, glucometer, scale, pulse oximeter) marked as patient-reported, with the source
• ☐Limits of the remote exam, and whether they affected decisions
• ☐Assessment and medical decision-making that support the level billed
• ☐Plan, follow-up format, and when the patient should seek in-person or emergency care

Step 3: Match the claim to the note (POS 02 vs POS 10, modifier 95 vs 93)

Use POS 10 when the patient is at home and POS 02 when they are anywhere else. Add modifier 93 for audio-only visits and modifier 95 for video, unless your payer says otherwise.

POS 10 generally pays the higher non-facility rate and POS 02 the facility rate, so a mismatch between the note and the claim is a common audit trigger.

• ☐POS matches the patient location in the note
• ☐Modifier 93 on every Medicare audio-only claim; FQ for audio-only at RHCs and FQHCs
• ☐Modifier 95 for video: industry sources disagree on whether Medicare still requires it, so confirm with your MAC; most commercial payers do
• ☐Code is on the Medicare Telehealth Services List or the payer's covered list
• ☐Time or MDM documented to support the code level
• ☐Medicaid and commercial rules checked, including whether they accept telemedicine E/M codes 98000–98015

Step 4: Cover the high-risk situations

Prescribing controlled substances via telehealth

Under the DEA's current extension, DEA-registered clinicians can prescribe Schedule II–V medications by telemedicine without a prior in-person exam through December 31, 2026. State rules can be stricter.

• ☐Drug, schedule, dose, quantity and medical purpose
• ☐Modality of the prescribing visit (audio-video in most cases; audio-only is narrower)
• ☐Date of any prior in-person exam
• ☐State PDMP check, with date, where required
• ☐State telehealth prescribing limits met
• ☐A plan for patients if the flexibilities lapse (buprenorphine for opioid use disorder and VA care have their own permanent rules)

Behavioral and mental health visits

• ☐Patient location confirmed at the start of each session, plus a safety and crisis plan
• ☐Privacy of the patient's setting checked
• ☐For Medicare telemental health, in-person visit timing tracked ahead of December 31, 2027

Cross-state care

• ☐License or compact privilege in the patient's state on the date of the visit
• ☐Patients traveling out of state flagged, with the rule you relied on

Step 5: Protect privacy and keep the record complete

• ☐Clinician in a private space; patient told who else is in the room
• ☐No recording without documented consent
• ☐Photos, images or messages from the patient saved to the chart, not left on personal devices
• ☐Note stored in the EHR and kept on the same schedule as in-person records
• ☐Privacy incidents (wrong patient joined, unsecured link) reported under your HIPAA policy

The 5-question test before you sign

If an auditor read only this note, could they answer these questions?

• Where were the patient and the clinician?
• How did they connect, and if audio-only, why?
• Did the patient consent to telehealth?
• What was examined remotely, and what could not be?
• Do the POS, modifier and code on the claim match the note?

If any answer is missing, fix the note before it reaches billing.

Frequently asked questions

Is verbal consent enough for telehealth?

In many states and for Medicare, verbal consent is acceptable if it is documented in the note with the date and who gave it. Some states require written consent, so check your state's rules.

What is the difference between POS 02 and POS 10?

POS 10 means the patient received telehealth at home. POS 02 means the patient was somewhere other than home, such as work or another facility. The code should match the location recorded in the note.

When should I use modifier 93?

Use modifier 93 when a visit is delivered by real-time audio only, with no video. Document why video was not used and that the patient agreed. RHCs and FQHCs use modifier FQ instead.

How long do Medicare telehealth flexibilities last?

The Consolidated Appropriations Act, 2026 extended Medicare's telehealth flexibilities through December 31, 2027. After that, they revert to stricter pre-pandemic rules unless Congress acts again.

Can I prescribe controlled substances by telehealth in 2026?

Yes. DEA flexibilities allow DEA-registered clinicians to prescribe Schedule II–V drugs via telemedicine without a prior in-person exam through December 31, 2026, subject to state law.

What should a telehealth exam note say?

Record only what you observed, label it as observed on video, mark home-device readings as patient-reported, and state any limits of the remote exam.

Sources

• KFF: What to Know About Medicare Coverage of Telehealth
• NASW: Two-Year Extension of Medicare Telehealth Flexibilities
• Federal Register: Fourth Temporary Extension of COVID-19 Telemedicine Flexibilities
• HHS: Prescribing controlled substances via telehealth
• Frier Levitt: DEA special registration final rule sent to OIRA
• Behave Health: Modifier 95 and Medicare Claims Processing Manual Ch. 26

Disclaimer: This article is for general information and is current as of October 2026. It is not legal, billing or medical advice. Confirm requirements with your payers, state boards and compliance team.