Telehealth psychiatry documentation: POS codes, modifiers, and what your note must show

By Selam Koch, PMHNP-BC, founder of OneStep Scribe and practicing psychiatric nurse practitioner. Published August 2026.

Psychiatry moved to telehealth faster and more completely than almost any other specialty, and for good reason: most of what we do is talk, observe, and decide. The clinical work translates. The billing and documentation do not translate automatically. A telehealth claim carries extra machinery, a place-of-service code that depends on where the patient is sitting, a modifier or two, and a handful of note elements that an in-person visit never needed. Miss any of them and a clean visit turns into a denial or, worse, a recoupment months later.

One warning before anything else, because it frames this entire guide: telehealth rules have changed repeatedly since 2020, at the federal level, at the state level, and payer by payer, and they are still changing. Everything below describes how the rules have stood recently and how they commonly work. None of it substitutes for checking the current policy of the specific payer you are billing. Where a rule is especially unstable, I say so.

The two telehealth place-of-service codes

The place-of-service code on a claim tells the payer where the service happened. For telehealth, two codes matter, and the difference between them is a single question you should ask at the start of every visit: where is the patient right now?

POS 10 was added in 2022, and payers adopted it at different speeds, which is part of why claims that used to pay suddenly stopped for some practices. As rules have stood recently, Medicare and most commercial payers expect POS 10 when the patient is at home and POS 02 when they are not, and some payers reimburse the two differently, with POS 02 sometimes mapping to a lower facility-style rate. A few payers still want telehealth billed under the office code with a modifier instead. That inconsistency is not your fault, but it is your problem: verify the expected POS convention with each payer you bill.

The practical habit is simple. Ask where the patient is, at every telehealth visit, and write it down. The answer sets the POS code, it is a documentation element many states and payers require anyway, and it occasionally surfaces a licensure issue you would rather catch at minute one than after the visit.

Modifier 95, and where modifier 93 comes in

Modifier 95 tells the payer the visit happened over live video with two-way audio. Many payers want it appended to the visit codes on a telehealth claim even when the POS code already says telehealth. Others treat the POS code as sufficient by itself, and a shrinking number still expect older telehealth modifiers instead. There is no universal rule here, only payer conventions, so build a small reference sheet for your actual payer mix and keep it current.

Modifier 93 is the audio-only counterpart. It indicates that the service was delivered synchronously by audio alone, with no video. When a payer covers audio-only behavioral health, this modifier is usually how the claim discloses it. Medicare also created its own audio-only modifier, FQ, for mental-health services, and some payers and settings (rural health clinics and federally qualified health centers in particular) expect FQ rather than, or in addition to, 93; confirm which audio-only modifier each payer wants. Billing an audio-only visit without disclosing it, on the theory that the code paid either way, is the kind of shortcut that reads very badly in a records review.

Audio-only visits

Audio-only telehealth went from essentially unbillable before 2020 to broadly covered for behavioral health during the public health emergency, and much of that coverage has persisted for mental health services, with conditions. As the rules have stood recently, Medicare has covered audio-only behavioral health visits when the practice has video capability but the patient cannot or will not use it, and it has expected the claim and the note to reflect that. Medicare's mental-health telehealth coverage also carries a statutory in-person visit requirement (an in-person encounter within six months before the first telehealth service and periodically thereafter) that Congress has repeatedly delayed rather than repealed; check whether a delay is currently in effect before relying on home-based or audio-only coverage. Commercial payers range from full audio-only parity to no audio-only coverage at all. This area has shifted more than once and may shift again, so treat any specific statement, including this one, as a prompt to check the current policy rather than a fact to rely on.

When you do conduct an audio-only visit for a payer that covers it, three things belong in the record: that the visit was audio-only, why it was audio-only rather than video (the patient's phone could not support video, the video connection failed, the patient declined video), and a mental status exam that honestly reflects what a phone call can support. More on that below.

One coding note before moving on: CPT now includes dedicated telemedicine E/M codes (98000 through 98016, with audio-only codes 98008 through 98015). Some commercial payers require these instead of office E/M codes with modifier 93, while Medicare does not pay most of them and expects standard codes with telehealth POS and modifiers. Check which convention each payer uses.

The five things a telehealth note should document

Beyond everything a psychiatric note normally has to contain, a telehealth encounter adds elements that payers and auditors commonly look for. Some are required by specific states and payers; the rest are cheap protection. Payer audits of telehealth claims look for these first, because they are the easiest things to find missing.

1. Patient location. At minimum the setting and state, for example "patient at home in New Jersey." This drives the POS code, and it is the documentation that shows you were authorized to treat the patient where they actually were.
2. Provider location. Where you were during the visit: office, home office, or another site. Some payers and some state rules care about this, and enrollment records increasingly need to match the locations you practice from.
3. Consent to telehealth. That the patient agreed to receive care by telehealth, after the format's limitations were explained. Some states and payers accept periodic consent, others expect it noted per encounter. One sentence per note satisfies the per-encounter documentation standard, but some states and payers additionally require written consent or specific consent content, so verify your state's telehealth consent rules once and build them into the intake packet.
4. Technology used. Real-time audio-video, or audio-only, and ideally that the platform was suitable for clinical use. If the connection failed mid-visit and you finished by phone, say so, because that can change the correct coding for the whole encounter.
5. Why telehealth was appropriate. A brief statement that this patient, at this visit, was suitable for remote care: clinically stable enough, no examination need that required in-person evaluation, no safety concern that demanded a different setting. This is also where clinical judgment shows its work when a reviewer asks why a patient in crisis was seen by video.

Video and audio-only visits document differently

The mental status exam is where telehealth documentation most often contradicts itself. On video you can legitimately observe appearance, grooming, psychomotor activity, eye contact, and affect, and you should document that the exam was performed over video. On an audio-only visit you cannot observe any of those things, and an MSE that reports "well groomed, good eye contact, no psychomotor abnormalities" on a phone call tells a reviewer that the exam text came from a template, not from the encounter. Once one section of a note is provably templated, every section of the note is suspect.

The honest audio-only MSE documents what a voice channel actually carries: speech rate, volume, and prosody, response latency, coherence and organization of thought as evidenced in conversation, mood as stated, affect as inferred from tone with that inference labeled, and a risk assessment conducted by direct questioning. It also notes what could not be assessed and why. That version is shorter, and it is stronger, because it matches the technology documented at the top of the note.

Risk assessment deserves one extra sentence in telehealth notes generally. Document safety planning with the patient's location in mind: who is with the patient, and what the plan is if the visit surfaces acute risk while you are 40 miles away. You will rarely need it. The one time you do, the note that shows you thought about it is the note you want in the chart.

Licensure: where the patient is sitting is where you are practicing

The general rule, and it surprises clinicians constantly, is that you must be licensed, or otherwise authorized, in the state where the patient is physically located at the time of service. Your license sits where the patient sits, not where you sit. A patient who moves to another state, a college student who goes back to campus, a snowbird who winters in Florida: each of these can quietly turn a routine follow-up into unlicensed practice if nobody asks the location question.

There are pathways that soften this: interstate compacts for some professions, temporary-practice allowances in some states, and registration options for out-of-state telehealth providers in others. They differ widely in scope and in which professions they cover, and they change. The safe workflow is unglamorous: ask location at every telehealth visit, document it, and when the answer is a state where you do not hold a license, resolve the licensure question with the relevant board before continuing care rather than after. This guide is not legal advice, and licensure questions are exactly where a licensing board or health-law attorney earns their fee.

Prescribing controlled substances by telehealth

Handle this section with more caution than any other, because the ground has moved under it repeatedly.

The baseline federal law is the Ryan Haight Act of 2008, which generally requires at least one in-person medical evaluation before a prescriber issues a controlled substance prescription by means of the internet, with limited exceptions. During the COVID public health emergency, federal flexibilities suspended that in-person requirement, and prescribers spent several years initiating controlled substances, stimulants and buprenorphine included, over telehealth alone. Those flexibilities were extended multiple times, proposed permanent rules were published and then revised after enormous public comment, and the special-registration pathway the law contemplated has been discussed for years. As of this writing the situation remains in motion.

What that means practically:

• Verify the current rule before you rely on it. Check current DEA guidance directly, not a secondhand summary with an unknown date, and recheck when renewals or new final rules are announced. A workflow that was compliant last year is not automatically compliant this year.
• Check state law separately. States regulate controlled-substance prescribing on top of federal law, and some are stricter, particularly for stimulants and for initiating controlled substances without an in-person exam. The stricter rule wins.
• Document more, not less. Identity verification at the first visit, the prescription drug monitoring program check, the clinical rationale for the medication, and why telehealth was an appropriate setting for this prescribing decision. If a rule change or an investigation ever puts your telehealth prescribing under review, that documentation is your account of having practiced carefully under the rules as they stood.

Common telehealth denial reasons

• Wrong place-of-service code. POS 02 when the patient was home and the payer wanted POS 10, or the reverse, or an office POS on a claim carrying a telehealth modifier. Some payers deny outright, others pay at the wrong rate and create a quiet underpayment.
• Missing or mismatched modifier. The payer wanted modifier 95 and the claim went out bare, or carried a legacy modifier the payer no longer accepts. Mechanically easy to fix, and easy to prevent with a per-payer reference sheet.
• Audio-only problems. A phone visit billed without modifier 93, or billed to a payer that does not cover audio-only for that code at all. The remittance often reads as a generic non-covered-service denial, which hides the real cause.
• No telehealth consent documented. This one rarely denies up front. It surfaces in records requests and post-payment reviews, where a missing consent line across many notes turns into a batch recoupment.
• Geographic or originating-site restrictions. Mostly a legacy of Medicare's pre-2020 framework, but versions of these restrictions persist in some plan designs and could return with future rule changes. When a telehealth denial makes no sense, ask the plan whether a site restriction applies.
• Code not on the payer's telehealth list. Payers maintain lists of which services they cover by telehealth, the lists differ, and they change with plan years. Add-on codes and testing codes fall off these lists more often than core E/M and psychotherapy codes.
• Location and licensure mismatches. A claim showing a patient state where the clinician holds no license, or a provider location that does not match enrollment records. Rare, but the consequences run well past the single claim.

Quick reference: telehealth claim mechanics

Frequently asked questions

What is the difference between POS 02 and POS 10?

POS 10 reports a telehealth visit with the patient located in their home, and POS 02 reports a telehealth visit with the patient located anywhere other than their home, such as a workplace, a car, or another clinic. Some payers pay the two codes differently, so ask where the patient is at the start of each visit and code from the answer. Verify how each payer you bill treats the two codes.

Do I still need modifier 95 if I am using a telehealth POS code?

Often yes, but it is payer-specific. Many payers want a telehealth POS code and modifier 95 together on audio-video visits, some treat the POS code alone as sufficient, and a few still expect a legacy telehealth modifier. Check each payer's current telehealth billing guidance rather than assuming one pattern covers your whole panel.

Can I bill an E/M with a psychotherapy add-on for a telehealth visit?

Many payers reimburse combinations such as 99214 with 90833 delivered by telehealth, and the documentation standard does not change: MDM-based E/M selection, separately stated psychotherapy minutes, and real therapy content. Coverage is payer-dependent, so confirm the add-on appears on each payer's telehealth-eligible code list before relying on it.

Is a phone-only session billable?

Sometimes. Audio-only coverage for behavioral health has been broader in recent years than it was before 2020, and Medicare has covered audio-only behavioral health visits under specific conditions as rules have stood recently. Commercial coverage varies widely. When a payer does cover audio-only care, expect to append modifier 93 and to document why the visit was audio-only rather than video. Note that CPT now includes dedicated telemedicine E/M codes (98000 through 98016, with audio-only codes 98008 through 98015); some commercial payers require these instead of office E/M codes with modifier 93, while Medicare does not pay most of them and expects standard codes with telehealth POS and modifiers. Check which convention each payer uses.

Does telehealth consent need to be documented at every visit?

Requirements vary by state and payer. Some accept consent obtained once and renewed periodically, while others expect consent noted at each encounter. A one-line statement in every telehealth note that the patient consented to the telehealth format costs nothing and satisfies the stricter documentation-frequency standard, so most practices simply document it every time. Check whether your state also requires specific consent content or written consent.

Can I treat a patient who is traveling or temporarily out of state?

Be careful. The general rule is that you must be licensed, or otherwise authorized, in the state where the patient is physically located at the time of the visit. Some states offer temporary-practice allowances or compact pathways, but they differ widely and change. Verify with the relevant state board before the visit, and document the patient's location either way.

Can I prescribe stimulants or other controlled substances by telehealth?

This is the least stable rule in the entire topic. Federal flexibility allowing controlled-substance prescribing via telehealth without a prior in-person exam has been extended repeatedly, and proposed permanent rules have gone through more than one revision. State law can be stricter than federal policy. Verify current DEA guidance and your state's rules before relying on telehealth alone, and document your reasoning carefully whenever you do prescribe.

Related guides

• Can you bill 99214 and 90833 together?
• An annotated 90833 note example
• 90832 vs 90834 vs 90837: choosing the psychotherapy code
• A complete psychiatric progress note example
• 90791 vs 90792: which intake code applies

This article is educational and reflects one clinician's understanding of coding rules at the time of writing. It is not legal, billing, or payer-specific advice, and it does not guarantee reimbursement or audit outcomes. Coding rules, payer policies, and state and federal laws change; always verify current requirements with your payers, coding resources, and compliance advisors, and consult your licensing board(s), current DEA guidance, and a healthcare attorney for licensure, consent, and controlled-substance questions. CPT is a registered trademark of the American Medical Association.