How to chart POS 10 vs 02 and telehealth consent in the note

Place of service 10 means telehealth in the patient’s home. Place of service 02 means telehealth somewhere else. Record city and state for the patient and for you, consent for this visit and this modality, and whether the visit was video (modifier 95) or audio-only (modifier 93). “Telehealth follow-up” in the chief complaint does not set POS.

The extra fields live in the telehealth follow-up template. What belongs in a telehealth psychiatry note is the essay version of the same gaps.

Confirm where the patient actually sat

Ask at the start. Write the answer.

Home (apartment, house, dorm room they live in) is POS 10 for Medicare telehealth billing. A parked car can still be “home” only if that is actually their residence story; a car outside work is not home. A workplace, hotel, friend’s house, school office, or another clinic is POS 02.

If they are in a different state from last visit, that is a licensure problem before it is a POS problem. Write the state. If you cannot treat them there, stop the visit and chart why.

Your location is the distant site. Write it. POS is about the patient’s originating site, but boards still want both.

Write consent, identity, and emergency geography

Consent for telehealth this visit, this modality. A 2023 blanket consent in the chart is not a substitute for “patient agreed to proceed by video today.”

Identity: how you knew it was them (camera plus name/DOB, or state-allowed alternative).

Emergency: current callback number and a physical address that EMS could use if they drop off mid-SI assessment. If they refuse to give an address, write that and what you did.

If the connection dropped and you finished by phone, the modality changed. The note and the modifier should change with it. See audio-only Medicare behavioral health when video fails.

Match POS 10 or 02 to that location

The claim’s POS must match the sentence in the note. Billers should not guess.

Medicare pays the non-facility rate for POS 10 and the facility rate for POS 02 on telehealth. That is why the two codes exist. Using 11 (office) on a video visit because “that is where I was sitting” is the classic mismatch.

Commercial payers sometimes want 11 plus 95. Follow the payer, but keep the clinical header honest: patient location still belongs in the note even if the claim uses a different POS convention.

Match modifier 95 or 93 to the technology

Modifier 95: synchronous real-time audio and video.

Modifier 93: synchronous audio-only. FQ is an additional Medicare modifier used in some RHC/FQHC and behavioral-health audio-only contexts. OTPs have their own rules.

Do not put 95 on a phone call. Do not put 93 on a visit where you could see them. If you saw them for 40 minutes and the last 5 were audio after a freeze, write the mix and follow the payer on which modifier dominates; honesty in the note comes first.

Sample telehealth header

Modality: real-time video (Zoom), modifier 95.
Patient location: home, Boise, ID. POS 10.
Clinician location: office, Boise, ID.
Identity verified on camera with name and DOB.
Consent: patient agreed to video telehealth for this visit.
Emergency address: [street], Boise, ID. Callback: [phone].
Connection: stable. Full exam limited to what was visible on camera
(head and torso). Gait not assessed.

Questions people ask

The patient was at their cabin. Is that home? If they reside there that day as a home, POS 10 is usually right. If it is a short rental, talk to billing; the note should still say “rental cabin, [city, state],” not “home” by habit.

Can I leave POS to the biller? You can let them translate. You cannot leave location out of the chart. They can only code what you wrote.