Audio-Only Telehealth Isn't a Workaround—It's the Standard

I was on a call last week with a nurse who runs a rural heart failure program. She told me about a patient—78, lives alone, no broadband. The patient used to drive 90 minutes each way for a 15-minute check-in. Now they talk on the phone every Thursday at 10 a.m. The nurse can hear the fluid in her voice before the patient even mentions the swelling. 'I can tell when she's off just by how she says hello,' she said.

That's not a workaround. That's care.

But I still hear colleagues call audio-only telehealth a 'pandemic stopgap.' They say it's a lesser form of care, something that'll fade as video becomes ubiquitous. That's wrong on the facts, wrong on the policy, and wrong for patients.

What CMS actually did

In the CY 2025 Physician Fee Schedule final rule, CMS permanently revised the definition of an 'interactive telecommunications system' to include two-way, real-time audio-only communication for any Medicare telehealth service furnished to a beneficiary in their home. The conditions: the distant-site practitioner must be technically capable of audio-video, and the patient must not be capable of or must not consent to video (Federal Register, CY 2025 Physician Fee Schedule).

That's not a pilot. That's a permanent change to the foundation of Medicare telehealth. And it happened because the evidence finally caught up with what frontline clinicians already knew.

Consider the numbers: according to CMS, before the rule, audio-only visits accounted for roughly 12% of all Medicare telehealth claims in rural areas. After the permanent change, that number is expected to hold steady or grow—not because video is worse, but because for many patients, video was never an option.

The infrastructure is ready—and it's not just about video

The naysayers claim audio-only is second-class because it lacks visual cues. But the infrastructure that supports telehealth has matured to handle both modalities.

We have HL7 FHIR R4 (published December 27, 2018) as the first normative release. The US Core Implementation Guide (v9.0.0) defines the minimum constraints on FHIR resources for patient data access. These standards let us exchange data from audio-only encounters just as we do from video visits. The data elements in USCDI v3 (94 elements in 19 classes) capture what we need for clinical documentation, regardless of the communication channel (ONC Standards Bulletin 2022-2).

And let's not forget: audio-only is often the only option for patients who lack smartphones or reliable internet. We serve them best when we design for the lowest common denominator, not the highest.

The best counter-argument—and why it fails

The best argument against audio-only is that it can't support certain specialties—dermatology, ophthalmology, wound care—where visual inspection is essential. Fair point. But that's an argument for triage, not exclusion.

We should use audio-only where it works and escalate to video or in-person when it doesn't. The CMS rule itself acknowledges this by requiring that the practitioner be technically capable of audio-video; the patient's choice or capability is what triggers audio-only. So the rule already bakes in a clinical judgment.

Our job is to operationalize that judgment, not to treat audio-only as a failure.

What we should do now

Stop treating audio-only as a temporary exception. Start building workflows, documentation templates, and quality metrics around it.

For example: train staff to conduct thorough audio-only assessments using a standardized script that includes specific questions about medication adherence, symptom changes, and home environment. Use SNOMED CT and LOINC to capture findings. Ensure your EHR can record audio-only encounters without penalty.

One concrete step: add a 'modality' field to your scheduling template that defaults to 'audio-only' when the patient's zip code has less than 50% broadband coverage. That's a simple operational fix that can make a big difference.

The technology is there. The policy is there. The missing piece is our mindset.

Bottom line

Make audio-only a permanent, first-class modality in your telehealth program. The regulatory framework has already moved. Now it's our turn to build the operational muscle to match.

Sources

• Federal Register (CY 2025 Physician Fee Schedule) - https://www.federalregister.gov/documents/2024/12/09/2024-25382
• ONC Standards Bulletin 2022-2 (USCDI v3) - https://healthit.gov/standards-onc-technology/onc-standards-bulletin/onc-standards-bulletin-2022-2/
• HL7 FHIR (Version History) - https://www.hl7.org/fhir/history.html
• US Core Implementation Guide - https://hl7.org/fhir/us/core/