Does a Practitioner Need to Document Time for a Telehealth Visit?

Question: 

Does a practitioner need to document time for a telehealth visit? What if it is audio only?

Answer:

First: For a telehealth visit, always document if it is with video or audio only. Documenting “telehealth visit” or “telemedicine visit” doesn’t differentiate this.

Second: If you are using office visit codes (99202—99215), you can select based on time or medical decision making. CPT telephone codes 99441–99443 are deleted in 2025. They are no longer in the CPT book. CPT has added audio/visual and audio only CPT codes (98000–98015).  These have an invalid status indicator from CMS and won’t be paid by Medicare. CMS is recognizing 98016 which replaces the HCPCS brief communications based technology service code G201, which was deleted.