Tele-Mental Health Documentation Requirements

What’s different about telehealth documentation

Format of session

Was the session conducted by video or phone?

For example: “Session provided via secure, HIPAA-compliant virtual platform.” or “Telephone session provided due to client preference and clinical appropriateness.”

Location of both client and provider

In most cases, it’s fine for the therapist and client to be in different states provided the client is in the state where the therapist is licensed. When client and therapist are in different states, documenting the location of both client and therapist ensures licensure compliance. For example:

When client and therapist are in the same state: “Client located at home in [state]. Provider conducting session from licensed home office in [state].”

If the therapist and client are in different states: “Client located in [state], where therapist is licensed. Therapist is located in [state].”

The client’s exact address is preferred but “address on file” is allowed for some states and insurance companies.

You’re limited by your state regulations, what your licensing board allows, and what your professional liability insurance covers. Make sure you review those.

Insurance and Billing Considerations

Telehealth coverage for mental health services is now standard, but requirements may vary by insurer, especially Medicaid or state-run insurance companies.

Document the correct Place of Service (POS)

• POS 02 for sessions anywhere but the client’s home.
• POS 10 for sessions in the patient’s home.

Some insurers still require modifiers such as 95 (synchronous telemedicine) or GT (legacy telehealth), so always confirm with your billing department or the payer.

Phone sessions are still covered when clinically appropriate, but documentation should note the reason video was unavailable and why the phone session was appropriate for the client.

Reimbursement for Telehealth

Most commercial insurance companies pay the same rate for the POS. Medicare, and some Medicaid companies pay lower for POS 02. Always check with the insurance company.

Informed Consent

Unlike during the early pandemic, non-HIPAA-compliant platforms should generally not be used. Secure video platforms and encrypted communication are now standard, and any deviations should be carefully documented with client agreement.

If ALL of the following are true, a non-secure video platform may be used when:

1. It’s clinically necessary

Examples:

• Secure platform is temporarily unavailable
• Client has no access to secure technology
• There is an urgent clinical need (crisis, safety concern)

2. The client is informed and consents

You must explain:

• The platform is not HIPAA-compliant
• The privacy risks
• Available alternatives (secure platform, phone, rescheduling)

The client must agree knowingly, and the agreement should be clearly documented. “Client consents to using a non-secure platform that is not HIPAA compliant and is aware of the risks.”

3. The platform is non-public facing

Allowed but not ideal

• FaceTime
• Skype (consumer version)
• Standard Zoom or Doxy, etc. (without BAA)

Not allowed:

• Facebook Live
• TikTok Live
• Twitch
• Public livestreams

4. Use is temporary

Best practice is to:

• Use it temporarily
• Transition back to a secure platform as soon as possible
• Do not make this your default telehealth setup

Rule: Non-secure platforms are exceptions, not standard practice.

How to Document Using a Non-Secure Platform

Transparency is key. If you do use a non-secure platform, your note should include all four elements:

Sample documentation language

Due to temporary unavailability of the secure telehealth platform, session was conducted via non-HIPAA-compliant video platform. Risks to privacy were discussed with client, alternative options reviewed, and client provided informed consent to proceed. No recording occurred. Plan to resume secure telehealth platform for future sessions.

This level and detail of transparency is what protects you.

When a non-secure platform is not allowed

Even with consent, it is not appropriate to use a non-secure platform when:

• A secure alternative is readily available
• It’s done for convenience alone
• It becomes routine practice
• Your informed consent forms don’t address this possibility

Consent does not override HIPAA obligations.

Staying Current

Tele-mental health rules continue to evolve. Stay updated with the payer guidance, state licensing boards, and federal regulations such as those from the Centers for Medicare & Medicaid Services. Regularly auditing your documentation can prevent compliance issues and protect your practice.

Telehealth Informed Consent

Is a signed telehealth consent required?

If only this was a simple yes or no answer…

Whether a consent is legally required depends on the state regs and the payer requirements.

Telehealth consent requirements are governed by:

• State law
• Licensing boards
• Medicaid rules (state-specific)
• Certain commercial payer policies

Some states explicitly require written consent, specific telehealth disclosures, and documentation that the consent was obtained prior to services. Other states do not require a separate signed telehealth consent and allow verbal consent (if documented).

So now what?

Legal requirement vs. best practice

Even in states where written consent is not explicitly required, a signed telehealth consent form is a risk management standard and therefore, best practice. A written consent protects you by documenting that the client understands:

• Privacy risks
• Technology limitations
• Emergency procedures
• Cross-state considerations (if applicable)
• Limits of confidentiality in virtual settings

Risk management recommendations

The bottom line is that a signed consent is important because it protects you if there’s a board complaint, audit, or lawsuit. Therefore, risk management experts highly recommend that you:

• Obtain a signed telehealth consent before the 1^st session.
• Store it in the client file.
• Reference it in the first note.

What about verbal consent?

Verbal consent is not best practice but may be acceptable if:

• Your state law allows it.
• It’s clearly documented.
• The documentation includes what was reviewed.

Here’s a simple and straight forward example of how to document verbal consent:

“Reviewed telehealth consent including risks, benefits, and emergency procedures. Client provided verbal consent to participate in telehealth services.”

However, though some states may allow verbal consent, it’s harder to defend, easier to dispute, and riskier in high-conflict or board complaint cases. Besides, if you’re verbally reviewing the risks, benefits, and emergency protocols of telehealth, you need a checklist to remember the details. Why not formalize it with a written consent?

Wise Wizard Advice

Telehealth’s unique challenges and considerations make a thorough informed consent a smart move even if your state doesn’t explicitly require it. It’s a document that takes five minutes to review and can prevent legal and ethical headaches (or nightmares) down the road.

That’s why Documentation Wizard consulted with a bioethicist and two attorneys to create a comprehensive Informed Consent for Telemental Health in easy-to-understand language and customizable to your practice and state standards.

The Documentation Wizard informed consent covers:

• The delivery and value of using telehealth
• Risks and benefits of using telehealth
• Alternative options to telehealth
• Confidentiality and Privacy and how to protect them
• Limits to Confidentiality
• Emergency Protocols and Contacts
• Technical Requirements
• How potential security breaches are handled
• How difficulties with technology are handled
• Recordings of the telehealth session

Available in our Informed Consent and Policies Package, we invested the time and money so you don’t have to. Customizing these Microsoft WORD documents for your specific practice needs and state requirements couldn’t be easier. We’ve highlighted areas in yellow that typically need your attention for easy identification. 

As an added bonus, you can skip the setup work. These forms come pre-loaded with your practice information so you can start using them right away.