Audio-Only Telehealth: Coding Risks and Documentation Must-Haves

The State of Audio-Only Telehealth

Audio-only telehealth was first broadly permitted under emergency COVID-19 public health flexibilities in 2020. Since then, Congress and the Centers for Medicare & Medicaid Services (CMS) have extended its allowance under select conditions through the Consolidated Appropriations Act.

In 2025, Medicare continues to reimburse audio-only services in specific scenarios, including behavioral health, primary care, and established patient visits. However, coverage and compliance vary drastically by payor, state, and clinical context, making documentation and coding precision more critical than ever.

Coding Risks and Pitfalls

One of the biggest challenges in coding audio-only encounters is ensuring the correct modifiers and place of service are used, and that the visit meets the criteria for medical necessity and time-based billing. Risk areas include:

• Incorrect or missing modifiers: Modifier 93 (introduced in 2022) must be appended to CPT codes that were delivered via synchronous audio-only communication;
• Wrong place of service: POS 02 (telehealth provided other than in the patient’s home) or POS 10 (telehealth in the patient’s home) must be used based on where the patient was located;
• Time-based billing errors: Without video interaction, providers must document the total time spent, as well as that more than 50 percent of the encounter was spent on counseling or coordination of care when using evaluation and management (E&M) time thresholds; and
• Payor inconsistency: Private and Medicaid payors may not recognize or reimburse services in the same way as Medicare, requiring health information management (HIM) and billing staff to crosswalk policies carefully.

Documentation Must-Haves

Proper documentation is non-negotiable for compliance and reimbursement. To ensure defensible records, providers should clearly include:

• Patient location at the time of the encounter;
• Provider location;
• Statement that the service was delivered via audio-only means;
• Reason audio-only was used;
• Clinical content, including symptoms, assessment, plan, and follow-up;
• Time spent, clearly documented in minutes; and
• Patient consent to conduct the visit via phone.

Additionally, provider attestation that no video was used is often recommended as part of internal compliance best practices.

What HIM and Coding Leaders Can Do Now

Organizations that haven’t already performed these steps should:

• Establish telehealth-specific documentation templates within their electronic health records (EHRs);
• Provide ongoing education to providers about appropriate billing for audio-only visits;
• Monitor payer-specific policies routinely for updates;
• Conduct retrospective audits of billed audio-only visits to assess coding accuracy and documentation completeness; and
• Collaborate with compliance teams to develop checklists for both front-end and back-end workflows.

Conclusion

Audio-only telehealth isn’t going away; it’s becoming a permanent fixture in hybrid care models. However, it brings with it a new level of complexity that must be addressed proactively. By aligning documentation and coding practices with evolving payer expectations, HIM and coding professionals can ensure that this accessible mode of care remains both compliant and sustainable.

Programming note:

Listen live today when Angela Comfort cohosts Talk Ten Tuesday with Chuck Buck, 10 am Eastern.