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Telehealth Encounter Documentation Template

Four documents and three sheets that audit telehealth encounters against five non-clinical elements, because the same note is complete for one payer and incomplete for another.

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What you get

Pack of 7 files: 4 documents, 3 spreadsheets

Telehealth Encounter Documentation Template
  • Requirement RegisterSpreadsheet
  • Consent FormDocument
  • Documentation Checklist by PayerDocument
  • Modality and Location NoteDocument
  • What Modifier 93 AssertsDocument
  • Encounter Documentation AuditSpreadsheet
  • Element FrequencySpreadsheet
RiverTelehealth Encounter Documentation Template

Encounter Documentation Audit

Five elements, none of them clinical, and none of them universal

One row per encounter. The element-missing column names the specific fact absent rather than an incomplete flag, and the charge is attached to it.

EncounterModalityPatient locationPractitioner video capabilityPatient declined videoConsent scope requiredModifier billedElement missingCharge
         
         

Three facts live only in the note

Modifier 93 asserts the patient was home, the practitioner could have used video, and the patient declined it or could not use it. None of the three is clinical, and a note missing one still bills and still pays.

Consent scope is a payer variable

One payer accepting an annual form and another wanting consent per encounter means the same signed form is a complete answer for one and a missing element for the other, with nothing on the note showing the difference.

Modifier 93 tells a payer three facts: the patient was at home, the practitioner was technically capable of using video, and the patient declined it or could not use it. None of the three is clinical, and almost none of them lives in a normal encounter note. An audio-only visit billed with modifier 93 and no capability statement produces a claim that pays anyway, because nothing on the claim reveals the absence, and the gap only surfaces in a retrospective review months later.

Consent scope hides the same way. Ridgeline Health wants consent renewed for the encounter in front of you. Summit Advantage and Cascade Mutual accept one signed form a year. One consent process therefore produces a complete note for two payers and an incomplete one for the third, using the same visit and the same template, and the note looks fine because a signed consent is sitting right there. At a fictional practice, Marchwood Behavioral Health, that one difference cost two encounters in a single month, both otherwise clean.

The audit checks five elements against what each payer actually requires, never against whether a service should have been delivered remotely. Results group two ways, by element and by payer, because the views disagree about what the problem is: Ridgeline's two gaps were both consent scope, while Summit Advantage's three gaps were three different facts on three different encounters. Eighteen encounters that month billed $2,971, and $1,114 of it, 37.5 percent, carried a payer-required element missing from the note, seven encounters in all.

Eighteen encounters, seven audio-only, and $1,114 riding on five fields nobody thinks of as documentation

The full encounter-level audit, the per-payer requirement register behind it, and the same gaps rolled up by element instead of by encounter.

Telehealth Encounter Documentation Template
RiverEncounter Documentation Audit

Encounter Documentation Audit

Illustrative figures for a fictional practice, Marchwood Behavioral Health, for one month. Eighteen encounters across three payers. "Support" asks whether the recorded elements support the billed modifier.

EncounterPayerModalityLocationConsent scope req.ModifierSupports itElement missingChargeStatus
TH-4101Summit AdvantageVideoHomeAnnual95Yes—148.00Complete
TH-4102Summit AdvantageAudio onlyHomeAnnual93Yes—148.00Complete
TH-4103Summit AdvantageAudio onlyHomeAnnual93NoPatient declined video148.00Element missing
TH-4104Summit AdvantageAudio onlyNot recordedAnnual93NoPatient location132.00Element missing
TH-4105Summit AdvantageVideoHomeAnnual95Yes—210.00Complete
TH-4106Summit AdvantageAudio onlyHomeAnnual93NoVideo capability148.00Element missing
TH-4201Ridgeline HealthVideoHomePer encounter95Yes—165.00Complete
TH-4202Ridgeline HealthVideoHomePer encounter95NoConsent for this encounter165.00Element missing
TH-4203Ridgeline HealthAudio onlyHomePer encounter93Yes—118.00Complete
TH-4204Ridgeline HealthVideoWorkplacePer encounter95NoConsent for this encounter165.00Element missing
TH-4205Ridgeline HealthVideoHomePer encounter95Yes—232.00Complete
TH-4301Cascade MutualVideoHomeAnnual95Yes—178.00Complete
TH-4302Cascade MutualVideoOut of stateAnnual95YesLicensure position178.00Element missing
TH-4303Cascade MutualAudio onlyHomeAnnual93Yes—142.00Complete
TH-4304Cascade MutualVideoHomeAnnual95NoConsent178.00Element missing
TH-4305Cascade MutualVideoHomeAnnual95Yes—196.00Complete
TH-4306Cascade MutualAudio onlyHomeAnnual93Yes—142.00House standard gap
TH-4307Cascade MutualVideoHomeAnnual95Yes—178.00Complete
Eighteen encounters Seven audio-only    Seven missing2,971.00Ten complete

TH-4306 is the row a single status field hides: Cascade Mutual's policy is silent on video capability and decline, so the audit marks it a house-standard gap rather than a required one, and it never shows up in the $1,114.00 required-element total. Ridgeline's three video visits (TH-4201/4204/4205) and one audio visit (TH-4203) share a payer and a month; only the two whose consent on file predates that specific encounter are incomplete, and both are otherwise clean notes.

RiverRequirement Register

Requirement Register

One row per payer, built from each payer's own telehealth policy document rather than a shared house assumption.

PayerAudio-only payableVideo capabilityPatient declinedConsent scopeConsent formAudio modifierVideo modifierPolicy document
Summit AdvantageYes, with conditionsRequired on audio-onlyRequired on audio-onlyAnnualWritten939542 CFR 410.78 + supplement TH-9
Ridgeline HealthYesRequired on audio-onlyRequired on audio-onlyPer encounterVerbal, documented9395Ridgeline policy TH-204
Cascade MutualYesSilentSilentAnnualWritten9395Cascade medical policy 22-118

Cascade Mutual's policy does not mention video capability or decline at all. Silent is recorded as its own value rather than treated as permissive, because the house standard keeps capturing both fields anyway and a policy revision that starts requiring them should not require rebuilding the template.

RiverElement Frequency

Element Frequency

The same seven required gaps rolled up by element, with the two silent-only misses kept in a separate column so they never inflate the priced total.

ElementMissing, requiredMissing, payer silentCharge where requiredPayer-specific or universal
Consent for this encounter20330.00One payer of three
Patient declined or could not use video11148.00Two payers of three
Video capability of the practitioner11148.00Two payers of three
Consent10178.00Universal
Licensure position for the patient's state10178.00Not a payer requirement
Patient location10132.00Universal
Total721,114.00Two of seven are payer-specific

Consent for this encounter is the single costliest element at $330.00, and it is entirely Ridgeline Health's: two encounters, both otherwise clean, both missing only because an annual-scope consent was on file instead of one dated to the visit.

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What's in the pack

01

Consent Form, Two Versions

Version A for an annual or once-per-relationship scope, version B adding the per-encounter block: date, modality, and the three checkboxes that carry two of the five payable elements on an audio-only visit. Intake usually collects version A once; see the patient intake pack.

02

Documentation Checklist by Payer

One column per payer rather than one house standard, because consent scope, video-capability requirements, and the modifier expected on audio-only differ by payer even though the encounter does not. Rows the payer's policy is silent on are marked silent, not skipped.

03

Modality and Location Note

Why modality is recorded explicitly rather than inferred from the platform, and why the patient's physical location, not the practitioner's, decides both which place-of-service code the claim carries and whether an out-of-state encounter needs to be routed to counsel.

04

What Modifier 93 Asserts

The three conditions the modifier verifies, quoted as fields rather than prose, and why the failure is silent in both directions: the claim pays either way, and the two facts are unreconstructable once the encounter is months old.

05

Requirement Register

One row per payer, carrying consent scope, the audio-only modifier, and the policy document and date behind each rule, so a changed policy shows up as a changed row instead of a surprised denial.

06

Encounter Documentation Audit

One row per encounter with the specific element missing named outright and the charge attached, never a generic incomplete flag. Eighteen encounters, seven of them audio-only, priced against $2,971 in the worked month.

07

Element Frequency

The same gaps rolled up by element instead of by encounter: which of the five costs the most, which are payer-specific, and where in the template each one would actually get captured.

08

Where the clinical half lives instead

This pack never reads the clinical narrative. A documentation improvement review reads what a coder would query in the note itself, and payer audits that request the encounters are the payer audit and RAC response pack's job.

How to use it

  1. 1

    Open in River, or download it

    Open the pack in River and let the agent build the requirement register from the payers actually on your panel, or download the blank Word and CSV files instantly and start with one payer.

  2. 2

    Fill consent scope before anything else

    Per encounter, per year, or once. It is the field that makes an identical note complete for one payer and incomplete for another, and no denial ever names it directly.

  3. 3

    Audit a batch of encounters

    Name the specific element missing on each one, never a generic incomplete flag, and attach the charge so the gap is a number and not just a note.

  4. 4

    Group by element, then by payer

    The two views disagree about what to fix. One tells the practice which field to add to the template; the other tells it which payer's requirement is producing the gaps.

Frequently asked questions

Is this template free?

Yes. Download the four documents and three sheets as Word and CSV files with no signup and no card. "Edit with AI" is a separate, optional path for practices that want the agent to audit real encounters against the payers actually on the panel. The rest of the library is at the template library.

Why does modifier 93 need three facts instead of one audio-only flag?

Because Medicare's own definition of an audio-only interactive telecommunications system is conditional: home, capable, declined. Drop any one and the claim carries a modifier the note does not support, and a coder cannot see that from the modifier alone. The note is the only place any of the three facts can live.

Why track consent scope separately from whether consent exists?

Because a signed consent and the right consent are different questions. An annual form on file answers one payer completely and answers a per-encounter payer not at all, and the note looks identical either way. Only the payer column shows which case you are in.

What happens when a patient is out of state during the visit?

The audit records the state and flags the encounter rather than resolving it. Whether a practitioner licensed in one state can treat a patient physically located in another is a licensure question, not a documentation gap, and this pack routes it out instead of guessing at a position.

Does the audit judge whether a visit should have been in person?

No. It checks whether five non-clinical facts are on the note, never whether the encounter was clinically appropriate to deliver remotely. That judgement belongs to the clinician. A documentation improvement review covers the clinical side this pack deliberately leaves alone.

Our practice already uses [a patient intake pack](/templates/patient-intake-pack) for consent. Does this replace it?

No, it extends it. Intake collects the standard consent once; this pack adds the per-encounter block a per-encounter payer requires and audits which encounters actually needed it. Most practices keep both, since intake consent rarely covers every payer's scope.

What format are the downloaded files?

Word documents for the consent form, the checklist, and the two notes, plus CSV for the three sheets, zipped into one download. They open in Word, Pages, Google Docs, Excel, Numbers, and Sheets without a conversion step.

Sources

  1. eCFR42 CFR 410.78 — Telehealth services (opens in a new tab)
  2. CMSPlace of Service Code Set (opens in a new tab)

Written by

Chandler Supple

Co-founder & CEO, River

Chandler has spent the last six years working in AI, building tools for millions of users and Fortune 100 companies. In 2025, he co-founded River to build a new kind of operating system for AI agents.

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Reviewed by

Brian Joseff, Co-founder, River

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Find out which of last month's telehealth encounters have a modifier the note doesn't support

Send the payer list and a month of encounters however they exist, an EHR export or a spreadsheet. The first thing back is every missing element named and priced, by encounter and by payer.

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