Telehealth Documentation: State-by-State Compliance in 2025

The telehealth landscape has changed significantly since the emergency flexibilities introduced in 2020, and many therapists are still operating under assumptions that no longer hold. The pandemic-era waivers that allowed therapists to see clients across state lines without additional licensure have largely expired or been codified into more permanent (and more varied) frameworks.

If you're doing any telehealth — and in 2025, almost every therapist is — it's worth doing a clear-eyed audit of your compliance posture.

What the Pandemic Changed (and What Stuck)

During the public health emergency, CMS and most state boards allowed significant flexibilities: therapists could practice across state lines, audio-only sessions were reimbursable, informed consent requirements were relaxed in many jurisdictions. As the emergency ended, these flexibilities were rolled back — but not uniformly, and not all the way.

What largely stayed:

• Many states made their telehealth-specific regulations permanent rather than reverting to pre-pandemic ambiguity
• Audio-only reimbursement for certain populations and payers (though this varies significantly by state and payer)
• Expanded platforms — many states clarified that any HIPAA-compliant platform is acceptable, rather than requiring specific clinical software

What largely ended:

• Blanket interstate practice waivers (with some exceptions through interstate compacts)
• Automatic equivalence of telehealth and in-person services for all codes and payers

The Interstate Compact Landscape

The PSYPACT (Psychology Interjurisdictional Compact) and the Counseling Compact are the most relevant frameworks for therapists practicing across state lines. As of 2025:

PSYPACT covers psychologists and has broad participation — over 40 states have enacted it. If you're a licensed psychologist, this is the most reliable pathway to interstate practice. You apply for an Authority to Practice Interjurisdictional Telepsychology (APIT), which allows you to see clients in all PSYPACT member states.

The Counseling Compact is newer and still growing. It covers licensed professional counselors and LCSWs (though LCSW inclusion varies by state enactment). Check the current member state list at the Counseling Compact Commission website — it's changing frequently.

LMFTs currently have the least favorable interstate landscape — there's no equivalent compact for marriage and family therapists, though several states have enacted their own bilateral agreements or temporary authorizations.

Social workers should check the Social Work Licensure Compact, which has been moving through state legislatures. The framework exists; participation is expanding.

The practical implication: if you're seeing clients in other states, "I was already licensed there" or "my home state license covers this" is almost never a complete answer. Know exactly which states your clients are connecting from, and verify your authorization in each.

Documentation Requirements by Category

Informed Consent for Telehealth

Nearly every state now requires a telehealth-specific informed consent separate from or supplementary to your general consent. What needs to be in it varies, but most state requirements include:

• Explanation of what telehealth involves and how it differs from in-person services
• Limitations of the technology (what happens if the connection drops)
• Emergency procedures — particularly important because you may not know the client's physical location
• Client's right to discontinue and request in-person services
• Privacy and security information about the platform being used
• Your licensure and where you're authorized to practice

Several states (California, New York, Texas among them) have specific statutory language requirements. Check your state board's current guidance rather than relying on a template you downloaded years ago.

Emergency protocols deserve special attention. Your consent document — and your session practice — should include a protocol for what happens if a client is in crisis during a telehealth session. This means you have their current physical address on file (not just their home address — if they travel, you need to know), a local emergency contact, and the nearest emergency services for their location.

Documenting the Session Location

This is a frequently overlooked requirement. Many states require you to document in your session notes:

• The platform used
• That the client was located in [state] during the session
• Whether the session was video, audio-only, or hybrid

The "client was located in [state]" piece matters for your jurisdictional compliance. If your client travels and doesn't tell you, and they're in a state where you're not authorized to practice, the location documentation in your notes becomes evidence of either compliance or violation.

Some therapists now start each telehealth session by verbally confirming location: "Just confirming you're still in [city, state] today?" It takes ten seconds and provides the basis for an accurate note.

Session Note Specifics

Beyond the above, telehealth session notes should be essentially equivalent to in-person notes. The modality of delivery doesn't change the clinical documentation requirements.

A few telehealth-specific additions that are good practice and sometimes required:

• Note any technical difficulties that occurred and their impact on the session
• If audio-only, note why (client preference, technical issues, state-specific authorization)
• Note the client's reported setting if relevant (at work, in a car, at a public location — this can affect the session clinically and is worth documenting)

Platform Requirements

The federal standard under HIPAA is that any platform used for telehealth must be HIPAA-compliant — meaning you've signed a Business Associate Agreement with the vendor. Consumer video platforms (FaceTime, Zoom without a HIPAA account, standard Google Meet) don't meet this standard.

Most states follow the federal floor and don't impose additional platform requirements beyond HIPAA compliance. A few exceptions:

Texas has issued guidance requiring certain security standards and BAA documentation to be available for audit.

New York has specific requirements around how telehealth services are marketed and described.

California continues to have among the most stringent privacy standards under the CMIA (Confidentiality of Medical Information Act), which in some respects exceeds HIPAA protections.

For most therapists using purpose-built telehealth platforms (Doxy.me, SimplePractice's built-in video, TherapyNotes' video, etc.), platform compliance is handled. What you need to ensure is that your BAA is current and you know where to find it.

Audio-Only Sessions

CMS permanently extended some audio-only reimbursement for Medicare beneficiaries in rural areas. Medicaid audio-only coverage varies dramatically by state. Commercial insurance audio-only reimbursement is a patchwork.

If you're billing audio-only sessions, verify:

• Your state's Medicaid policy on audio-only
• Your specific commercial panel's current policy (these have been in flux)
• Whether the CPT codes you're using are appropriate for audio-only delivery

From a documentation standpoint, audio-only sessions should be clearly noted as such in your records. Some payers require specific modifiers when billing audio-only.

The Audit Risk

Telehealth is a significant area of insurance fraud enforcement. Billing for services not rendered, upcoding session complexity, and improper interstate practice are active audit targets. Your documentation is your defense.

The practical upshot: telehealth documentation should be as thorough as your in-person documentation, plus the telehealth-specific elements above. If you're ever audited for telehealth claims, reviewers will be looking at whether your notes demonstrate that sessions actually happened, were clinically substantive, and were delivered in compliance with applicable requirements.

Staying Current

Telehealth regulation is still evolving. The most reliable sources for current requirements:

• Your state licensing board's website
• Your state association's practice resources
• Interstate compact commission websites for current member state lists
• Your malpractice insurance carrier — most publish telehealth compliance guides and will answer questions

This is one area where checking annually rather than assuming nothing has changed is genuinely important. The landscape has been shifting fast enough that last year's compliance assumptions may not hold today.