Denied telehealth claims are more than just a hassle—they’re a direct hit to your practice’s bottom line. The culprit is often a simple mix-up with telehealth billing codes. This confusion is getting worse as new codes are introduced while some payers stick to the old methods. Suddenly, you’re managing two different systems. This isn’t just an administrative problem; it’s a financial one that disrupts your cash flow. We’ll show you exactly how to select the right codes for the right payer, protect your revenue, and streamline your entire billing workflow.
Key Takeaways
- Master Payer-Specific Rules: Don’t assume one billing method works for all insurers. Medicare is sticking with established E/M codes plus modifiers (like 95 or 93), but private payers may use new dedicated telehealth codes or have their own unique requirements. Always verify each payer’s policy before submitting a claim to prevent denials.
- Build a Proactive Billing Workflow: To ensure you’re paid correctly, focus on prevention, not just reaction. Train your team to choose codes based on service complexity or time, establish a final review process to catch errors before claims are sent, and regularly audit your payments to catch and correct underpayments.
- Stay Ahead of Constant Changes: Telehealth billing rules are always evolving. Protect your revenue by regularly following updates from CMS and professional groups like the AMA, keeping your billing software current with the latest codes, and making ongoing education a standard practice for your team.
What Are Telehealth Billing Codes and Why Are They So Important?
If your practice offers virtual appointments, you need to get paid for them. That’s where telehealth billing codes come in. Think of them as the specific language you use to communicate with insurance companies, detailing exactly what service you provided remotely. Using the right codes is the difference between a smooth payment process and a denied claim that costs you valuable time and money. Getting this part of your operations right is non-negotiable for a thriving practice.
These codes are more than just administrative details; they are fundamental to your practice’s financial health. As telehealth solidifies its place as a permanent fixture in healthcare, mastering its billing nuances is no longer optional. It’s an essential skill for maintaining a healthy revenue cycle and ensuring you’re properly compensated for the critical care you provide. Getting this right means you can continue to offer flexible, accessible care to your patients without sacrificing your bottom line. It’s about building a sustainable future for your practice in a changing healthcare landscape, and it all starts with understanding the codes.
What Exactly Are Telehealth Codes?
Telehealth billing codes are specific CPT and HCPCS codes that identify services delivered via technology like video calls or phone calls. Often, you’ll use a standard evaluation and management (E/M) code along with a special modifier (like 95 or GT) to show the service was performed remotely. These codes and modifiers give payers the full picture: what you did, how you did it, and why it should be reimbursed. Your billing staff must be fluent in these details to prevent errors and ensure clean claims are submitted the first time.
How These Codes Affect Your Practice’s Bottom Line
Simply put, using the correct telehealth codes is how you get paid for your virtual services. Incorrect coding is one of the fastest ways to trigger claim denials, which disrupts your cash flow and creates extra administrative work for your team. To keep your revenue cycle healthy, your providers and billing staff need to be on the same page. This requires ongoing education to stay current with changing payer rules and technology. Establishing clear educational and training standards ensures everyone is comfortable with the tools and confident in the billing process, which is a cornerstone of efficient practice management.
Understanding Telehealth Reimbursement Rates
It’s a common misconception that telehealth visits are reimbursed at the same rate as in-person appointments. While the “work” component of the service might be valued similarly, the total payment for telehealth is often lower. This is because reimbursement calculations account for practice expenses, which are typically less for a virtual visit than for one requiring a physical office space. As a result, audio/video telehealth visits are generally paid less than in-person services, and audio-only visits are reimbursed at an even lower rate. Understanding this payment structure is key to accurately forecasting your revenue and setting realistic financial expectations for your telehealth services.
The complexity doesn’t stop there. Different payers have different rules. For instance, Medicare has stated it will continue using established E/M codes with specific telehealth modifiers (like 95 for audio/video) rather than adopting new dedicated telehealth codes. However, private insurance companies may have entirely different requirements. This variability means you must check each payer’s specific policy before submitting a claim. Keeping up with these ever-changing rules, like the updates in the Medicare Physician Fee Schedule, is a significant administrative burden. This is precisely where an expert billing partner can make all the difference, ensuring your claims are coded correctly for every payer, every time.
Securing Your Reimbursement with the Right Codes
The codes you choose directly impact your bottom line. Using a code that doesn’t fully capture the complexity of a virtual visit can lead to underpayment, leaving money on the table. On the other hand, incorrect coding can raise red flags with payers, potentially leading to audits. Accurate billing is crucial for maximizing your reimbursement and maintaining compliance. By ensuring every claim is coded correctly, you secure the full payment you’ve earned for your services. This attention to detail is a key part of a successful medical billing strategy and protects your practice’s financial stability.
A Guide to Current Telehealth Billing Codes
As telehealth solidifies its place in modern healthcare, the billing codes are finally catching up. The temporary rules we all adapted to during the pandemic are making way for a more permanent, structured system. For your practice, this means getting comfortable with a new set of codes while also knowing when to stick with established methods. Keeping on top of these changes is absolutely essential for maintaining a healthy revenue cycle and preventing unnecessary claim denials. Let’s walk through what you and your team need to know to bill confidently in 2025.
Essential CPT Codes for Telehealth Services
A new series of CPT codes, 98000-98016, has been created specifically for telehealth services. These codes are designed to bring long-term consistency to virtual care billing, moving away from the temporary fixes of the past few years. The goal is to standardize how telehealth encounters are reported, making the process clearer for everyone. For practices that want to see the full details, the Society for Maternal-Fetal Medicine provides a helpful summary of the new 2025 telehealth CPT codes. Successfully adopting these codes will require training your team to ensure they’re used correctly from day one.
Codes for Virtual Check-ins
Virtual check-ins are brief, patient-initiated communications that help you decide if an in-person visit is necessary. These aren’t full appointments but quick touchpoints to address a patient’s concern. For these interactions, you’ll use code G2010 when reviewing recorded video or images sent by a patient. The key requirement is that you must provide a follow-up within 24 business hours. It’s also important to note that this service cannot be related to an in-person visit that occurred within the last seven days or one that is scheduled within the next 24 hours. Proper use of this code ensures you’re compensated for the time you spend on these valuable, time-saving interactions.
Codes for e-Visits and Online Digital Services
When an established patient reaches out through your online portal for non-urgent advice, you’re providing an e-Visit. These digital services are billed based on the cumulative time you spend on the interaction over a seven-day period. The codes are straightforward: use 99421 for 5-10 minutes of work, 99422 for 11-20 minutes, and 99423 for 21 minutes or more. Documenting your time is critical here, as it directly determines the code you can use. These codes allow you to bill for the asynchronous care you provide, ensuring you’re paid for your expertise even outside of a traditional appointment.
Codes for Remote Patient Monitoring (RPM)
Remote Patient Monitoring (RPM) allows you to track a patient’s health data, like blood pressure or glucose levels, from a distance. This service involves a few different codes. CPT code 99454 covers the supply of the monitoring device and patient education on how to use it. For the time your clinical staff spends monitoring the data and interacting with the patient, you’ll use 99457 for the first 20 minutes per month. If more time is needed, each additional 20 minutes is billed with 99458. Correctly billing for these services ensures your practice is reimbursed for the ongoing care you provide to patients with chronic conditions.
Codes for Specialized Telehealth Care
Telehealth extends far beyond primary care, with specific codes available for various specialties. For example, telebehavioral health has become a critical service, and its billing reflects that. You’ll typically use standard CPT codes for psychiatric diagnostic evaluations (90791) and psychotherapy (90832-90837), but you’ll add a telehealth modifier like 95 to indicate the service was provided remotely. This same principle applies to many other specialties, from cardiology to dermatology. The key is to use the correct base CPT code for the service provided and pair it with the appropriate modifier required by the payer to ensure accurate and timely reimbursement for your specialized virtual care.
How to Correctly Apply Telehealth Modifiers to E/M Codes
While new codes are arriving, the familiar method of billing for telehealth isn’t going away. Practices will still use standard in-person Evaluation and Management (E/M) codes, like 99202-99215, and simply append a modifier to show the service was virtual. Modifier 95 is for appointments with both audio and video, while modifier 93 is for audio-only calls. This method remains critical because some major payers will continue to require it. Knowing whether to use a new dedicated code or an E/M code with a modifier will depend entirely on the payer, making accurate medical billing more nuanced than ever.
Audio-Only vs. Audio/Video: When to Use Each Code
The new 2025 codes draw a clear line between different types of telehealth appointments. Codes 98000-98007 are for visits that use both audio and video, like a typical video consultation. On the other hand, codes 98008-98015 are specifically for audio-only services, such as a phone call. There’s a key rule to remember for audio-only visits: for the service to be billable under these new codes, the medical discussion with the patient must last for at least 10 minutes. This requirement helps ensure you’re billing only for substantive consultations, which is vital for staying compliant and getting paid for your time.
Decoding Medicare’s Telehealth Code Policies
This is a crucial piece of information for any practice that serves Medicare patients: Medicare has announced it will not accept the new 2025 telehealth codes (98000-98015). Instead, you must continue using the established method—billing with regular E/M codes and appending modifier 95 or 93. This difference between Medicare and other commercial payers is a major potential pitfall. It can easily lead to confusion and a spike in claim denials if your billing team isn’t aware of the distinction. This highlights why strong practice management protocols are so important for verifying payer-specific rules.
Understanding Place of Service (POS) Codes
Beyond the CPT code and modifier, there’s one more critical detail: the Place of Service (POS) code. This two-digit code tells the insurance company *where* the patient was physically located during their virtual appointment. It might seem like a minor detail, but it directly affects your reimbursement rate. For telehealth, the two codes you need to know are POS 02 and POS 10. Choosing the correct one is essential for submitting a clean claim, as a mismatch can easily trigger a denial. Getting this right is a fundamental part of a streamlined medical billing process that protects your revenue.
So, what’s the difference? Use POS 02 when the patient is receiving telehealth services anywhere *other than their home*—for example, at a local clinic or even their office. Use POS 10 when the patient is at home. This distinction is especially important for Medicare, which pays a lower “facility rate” for POS 02 claims but a higher “non-facility rate” for POS 10. Since commercial payers may have their own rules, it’s vital to confirm the correct POS code with each insurer. This constant need for verification is why many practices rely on expert support to ensure every claim is accurate.
How to Choose the Right Telehealth Billing Code
Choosing the correct telehealth billing code isn’t just about getting paid—it’s about accurately representing the care you provided and staying compliant. With so many codes and payer-specific rules, it can feel like a moving target. The key is to have a clear, consistent process for every virtual encounter. This means looking beyond just the patient’s diagnosis and considering the full context of the visit, from the technology used to the complexity of the conversation.
Think of it as telling the complete story of the patient visit through a series of numbers and letters. When you select the right code, you ensure your practice receives fair reimbursement for your time and expertise. Getting it wrong can lead to claim denials, payment delays, and even audits. By focusing on a few key factors for each telehealth appointment, you can build a reliable system that protects your practice’s financial health and lets you focus more on patient care. Our team at AMS Solutions specializes in helping practices streamline this entire process, ensuring accuracy from start to finish.
Aligning Codes with Medical Decision-Making (MDM)
The complexity of the medical decision-making (MDM) involved in a patient visit is a cornerstone of accurate E/M coding, and telehealth is no exception. MDM measures the intensity of the work required to diagnose and treat the patient. It’s based on three elements: the number and complexity of problems addressed, the amount and complexity of data reviewed, and the risk of complications or morbidity. Your billing staff must understand these nuances, as higher levels of MDM justify higher-level codes and, consequently, higher reimbursement. Proper documentation that supports the level of MDM is critical for a clean claim.
Should You Use Time-Based Billing?
For many telehealth services, you have the option to select a code based on the total time spent on the day of the encounter. This includes both the face-to-face time with the patient and other qualifying activities, like reviewing records, coordinating care, and documenting the visit. Time-based billing can be particularly useful for visits that involve extensive counseling or care coordination but may not meet the criteria for a higher level of MDM. To use this method, you must meticulously document the total time spent and provide a summary of the activities performed. This approach requires a proactive system for tracking time to ensure your billing and coding is both accurate and defensible.
How to Match Codes to Your Service Type
Not all virtual interactions are created equal. A quick, five-minute virtual check-in to see if a patient needs an in-person visit is billed differently than a comprehensive 40-minute consultation for a complex chronic condition. It is essential to match the CPT code to the specific type of service you provided. This means distinguishing between services like virtual check-ins, e-visits (patient-initiated digital communications), and full audio/video telehealth appointments. Using the wrong code can lead to immediate denials. Implementing continuous training for your providers and billing staff helps ensure everyone understands these distinctions and can select the most appropriate code every time.
Understanding the Limitations of Audio-Only Codes
While audio-only telehealth became a lifeline for many, its billing rules are often more restrictive than those for audio-visual visits. Many payers, including Medicare, have specific lists of services that can be provided via telephone, and reimbursement rates may be lower. It’s important to know these limitations before you provide and bill for an audio-only service. Always verify payer policies, as some may not cover audio-only visits at all or may have different documentation requirements. Being aware of these rules helps you set patient expectations and avoid unexpected claim rejections. For more detailed guidance, you can review the best practice standards from government resources.
What Do Medicare and Insurers Require for Telehealth Billing?
Getting telehealth billing right often feels like trying to hit a moving target. Each payer—from Medicare to the smallest private insurer—has its own set of rules and requirements. What one company accepts, another might deny. This lack of standardization is one of the biggest hurdles for medical practices. To ensure you’re getting paid accurately and promptly for the virtual care you provide, you need to understand the specific guidelines for each payer you work with.
The key is to treat each payer as a unique entity. Medicare has established its own clear path, while private insurers often create their own policies, and Medicaid rules can change completely just by crossing a state line. Staying on top of these different requirements is essential for maintaining a healthy revenue cycle. Let’s break down what you need to know about the major players so you can bill with confidence and avoid unnecessary claim rejections.
Medicare’s telehealth rules
When it comes to telehealth, Medicare has decided to stick with what it knows. Despite the introduction of new telehealth-specific CPT codes for 2025, Medicare has stated it will not be using them. Instead, you should continue to bill for telehealth services using the standard Evaluation and Management (E/M) codes, just as you would for an in-person visit. The crucial difference is adding the correct modifier to indicate the service was provided remotely.
For most audio-video telehealth visits, you’ll use modifier 95. If the service was audio-only, you’ll use modifier 93. Using these modifiers correctly is non-negotiable for getting your Medicare claims paid. Always double-check the list of covered telehealth services to ensure the care you provided is eligible for reimbursement.
Geographic and Service Restrictions
One of the most challenging aspects of telehealth billing is that the rules are not universal. A code that works for a private insurer in one state might be denied by Medicaid in the neighboring one. Medicare has its own specific guidelines, while commercial payers often create their own unique policies. This patchwork of regulations means your billing team must verify the rules for each specific payer and patient location. Staying on top of these ever-changing requirements is a significant administrative burden but is absolutely essential for maintaining a healthy revenue cycle and preventing avoidable claim denials.
In-Person Visit Requirements for Mental Health
For mental and behavioral health providers, Medicare has a critical rule for telehealth services delivered to a patient at home (Place of Service 10). Before you can begin providing these services, the patient must have had a traditional, in-person visit with a physician or qualified non-physician practitioner within the last six months. After the initial telehealth service, an in-person visit is required at least every 12 months. This rule is designed to ensure continuity of care and is a key compliance point that mental health practices must track carefully to ensure reimbursement.
Documentation Rules for Audio-Only Visits
When a patient chooses a phone call over a video appointment, your documentation needs to explain why. To successfully bill for an audio-only service, your patient’s record must clearly show that video was an available option, but the patient either declined or was unable to use it. This small but crucial detail provides the justification payers need to see. Without it, you risk having the claim denied. Proper documentation is your best defense, proving that you followed protocol and that the service was medically appropriate and delivered according to the patient’s needs and capabilities.
Understanding Communication Technology-Based Services (CTBS)
It’s important to recognize that not all remote care is considered a formal telehealth visit. Services like brief virtual check-ins or patient-initiated e-visits fall into a category called Communication Technology-Based Services (CTBS). A key advantage of CTBS is that these services typically do not have the same geographic restrictions as traditional telehealth. This means the patient can be located anywhere when they receive the service. Understanding the distinction can open up new avenues for providing and billing for care, making your practice management more flexible and efficient.
How to Handle Private Payer Policies
Unlike Medicare, the world of private insurance is far less uniform. There is no single rule for how commercial payers handle telehealth billing, which means you’ll need to do a little homework. Some insurance companies may decide to adopt the new 2025 telehealth codes, while others might follow Medicare’s lead and require E/M codes with modifiers. A few might even have their own unique billing requirements.
The only way to know for sure is to ask. Before you submit a claim, it’s best practice to contact each insurance company directly to confirm their specific telehealth billing protocol. Verifying their rules upfront will save you from the headache of claim denials and delayed payments down the road. Make this a standard part of your verification process.
What to Know About Medicaid Coverage Rules
Medicaid adds another layer of complexity because it’s administered at the state level. This means that the telehealth billing rules for Medicaid in one state can be completely different from the rules in a neighboring state. Everything from which services are covered to which codes and modifiers are required can vary significantly. This decentralized approach requires practices to be diligent about understanding their local regulations.
To ensure compliance and proper reimbursement, you must refer to your specific state’s Medicaid agency for guidance. These agencies publish their own provider manuals and billing guidelines that outline their telehealth policies. You can find helpful resources and links to state-specific information on the official Telehealth.HHS.gov website. Never assume that a rule from one state applies to another.
Simple Tips for Documentation and Compliance
No matter who the payer is, thorough documentation is the foundation of successful telehealth billing. Your notes should clearly support the level of service billed and include details confirming the patient consented to telehealth, the technology used, and the location of both you and the patient. Keeping detailed records is your best defense against audits and denials.
Because telehealth policies are constantly evolving, staying current is critical. Regularly check for updates from Medicare, your state’s Medicaid program, and the private payers you work with. This can feel like a full-time job, which is why many practices choose to partner with a billing service. Having experts manage the complexities of payer requirements ensures your claims are clean, compliant, and paid correctly, freeing you up to focus on patient care.
Guiding Patients on Their Coverage
Patients are often just as confused about telehealth coverage as practices are, and they look to you for answers. Your front office team can play a crucial role by proactively verifying benefits before a virtual visit. This simple step allows you to clearly explain any potential copays, deductibles, or non-covered services, preventing surprise bills and frustrated phone calls down the line. This transparency builds trust and shows patients you are invested in their overall experience, not just their clinical care. It’s a cornerstone of effective practice management that improves patient satisfaction and ensures a smoother financial process for everyone involved.
Common Challenges in Telehealth Billing
Telehealth offers incredible flexibility for you and your patients, but the billing process can feel like a puzzle. Many practices run into the same few hurdles. Knowing what they are is the first step to building a smoother, more efficient billing workflow that keeps your revenue cycle healthy. These challenges often revolve around complex rules, technology gaps, and the constant pace of change. By understanding them, you can put the right strategies in place to protect your practice’s financial health.
Juggling Complex Codes and Payer Differences
One of the biggest headaches in telehealth billing is that there’s no universal rulebook. Each payer—from Medicare to the private insurer down the street—has its own set of requirements for which codes and modifiers to use. Your billing team needs to be fluent in the specific nuances of telehealth billing, like knowing when to apply modifier 95 versus GT, or which Place of Service (POS) code is correct for a given encounter. Without this deep knowledge, it’s easy for small mistakes to lead to rejected claims. This is why ongoing education for your billing staff isn’t just helpful; it’s essential for getting paid correctly and on time.
How to Address Claim Denials and Payment Delays
It’s frustrating to provide excellent care only to have the claim denied. Unfortunately, denials are a common part of telehealth billing, often stemming from the coding complexities we just talked about. A simple mistake, like a missing modifier or an incorrect diagnosis code, can bring the payment process to a halt. Other times, it’s an issue with prior authorization or patient eligibility. A proactive approach is your best defense. By having a system to review claims before submission and quickly address denials when they happen, you can protect your practice’s cash flow. This is where having an experienced medical billing partner can make a significant difference.
Making Sure Your Tech and Billing Systems Work Together
Your telehealth platform and your billing software should work together seamlessly, but that’s not always the case. When these systems aren’t properly integrated, it creates extra work and opens the door for manual data entry errors. Information from a virtual visit might not transfer correctly, leading to inaccurate claims. It’s also crucial that your entire team, from providers to front-desk staff, feels comfortable using the technology. Proper training on your telehealth systems ensures that everyone captures the necessary information correctly from the start, which makes the billing process much smoother down the line.
Staying on Top of Changing State-by-State Rules
Telehealth regulations are constantly changing, and they vary significantly from one state to another. Rules around provider licensing, patient consent, and what services are covered can differ, creating a complex web for practices that see patients across state lines. For example, one state might have strong payment parity laws ensuring telehealth is reimbursed at the same rate as in-person visits, while a neighboring state may not. Staying on top of these evolving state policies is a major challenge. It requires continuous monitoring and education to ensure every claim you submit is compliant with the latest regulations in your patient’s location.
How to Overcome Telehealth Billing Challenges
Telehealth billing can feel like a moving target, with its own set of codes, payer rules, and compliance hurdles. But these challenges don’t have to disrupt your practice’s revenue cycle. With a few smart strategies in place, you can handle the complexities of telehealth billing, reduce claim denials, and ensure you’re paid accurately for the care you provide.
The key is to be proactive rather than reactive. Instead of waiting for problems to arise, you can build a system that anticipates them. This involves keeping your team sharp, your communication lines open, and your processes airtight. By focusing on education, clear communication with payers, and diligent internal reviews, you can create a billing workflow that is both efficient and effective. These steps will help you manage the nuances of virtual care and maintain a healthy financial outlook for your practice.
Invest in Training and Educating Your Team
The world of telehealth billing is constantly changing, which means ongoing education for your staff isn’t just a good idea—it’s essential. Your billing team is on the front lines, so they need to be completely up-to-date on the latest codes, modifiers, and documentation requirements. Implementing regular training sessions ensures everyone is on the same page and understands the specific rules for different payers. When your team is confident and knowledgeable, they can submit cleaner claims, reduce errors, and spend less time dealing with rejections. This investment in education pays off by creating a smoother, more efficient billing process.
Establish Clear Communication with Payers
Don’t wait for a claim denial to find out you’ve missed a payer-specific requirement. Establishing a clear line of communication with insurance companies is one of the most effective ways to prevent billing headaches. Reach out to your payer representatives to clarify their telehealth policies, documentation needs, and any recent updates. This proactive approach helps you understand exactly what they expect, reducing the risk of misunderstandings that lead to delayed or denied payments. Keeping a record of these communications can also be a valuable resource for your billing team, ensuring consistency and accuracy across all submissions.
Create a Proactive Claim Review Process
Even the most experienced billing specialist can make a mistake. That’s why a systematic claim review process is so important. Before any claim goes out the door, have a system in place for a final check. This internal audit helps catch simple errors like typos, incorrect codes, or missing information that could trigger an automatic denial. By identifying and fixing these issues before submission, you significantly increase your first-pass claim rate. This simple step saves your team the time and frustration of reworking denied claims and helps speed up your reimbursement cycle.
Develop a System for Monitoring Payments
Submitting a clean claim is only half the battle; you also need to make sure you’re getting paid correctly. Consistently monitoring your payments is crucial for catching underpayments or improper denials. Set aside time to regularly review your explanation of benefits (EOB) and electronic remittance advice (ERA) to compare payments against your contracted rates. If you spot discrepancies, you can follow up immediately. This diligence not only protects your practice’s revenue but also helps you identify recurring issues with specific payers, allowing you to address the root cause and improve your cash flow.
Consider Partnering with a Professional Billing Service
If your team is feeling overwhelmed by the complexities of telehealth billing, it might be time to bring in an expert. Partnering with a professional billing service can lift a significant weight off your practice. A dedicated medical billing company lives and breathes this stuff—they stay on top of changing regulations and payer requirements so you don’t have to. This frees up your staff to focus on patient care and other critical administrative tasks. It’s a strategic move that can lead to fewer errors, faster payments, and a healthier bottom line for your practice.
How to Stay Current with Telehealth Billing Changes
The rules for telehealth are constantly evolving, which means the billing requirements change right along with them. Keeping up with these shifts is essential for maintaining a healthy revenue cycle and avoiding claim denials. It requires a proactive strategy that goes beyond just memorizing codes. You need to stay informed about new payer policies, regulatory updates, and technological advancements. Let’s walk through some practical steps you can take to ensure your practice stays ahead of the curve and gets reimbursed accurately for the virtual care you provide.
Find the Right Resources and Tools
Your team is your greatest asset, and equipping them with the right knowledge is the first step to success. Telehealth billing isn’t something you can learn once and forget; it requires ongoing education. Implementing continuous training and education programs for everyone involved in the billing process ensures they are prepared to handle the complexities of virtual care reimbursement. This includes regular check-ins on new codes, modifier usage, and payer-specific rules. Investing in the right tools, from up-to-date software to a reliable medical billing service, can also make a significant difference in your efficiency and accuracy.
Lean on Professional Association Guidance
You don’t have to go it alone. Professional organizations like the American Medical Association (AMA) and the American Academy of Professional Coders (AAPC) are fantastic resources for the latest information. These groups provide detailed guidance, webinars, and publications dedicated to telehealth billing. Your billing staff must be well-versed in the nuances of
Keep a Close Eye on Regulatory Updates
Government and private payer policies are the foundation of telehealth billing, and they can change quickly. It’s crucial to monitor updates from the Centers for Medicare & Medicaid Services (CMS), as their policies often set the standard for other insurers. You should also keep a close eye on your state’s Medicaid policies and any specific rules from the private payers you work with most. Successfully managing telehealth billing demands a proactive approach, so consider subscribing to newsletters from CMS and other key organizations to get timely information delivered directly to you.
Why You Must Keep Your Billing Software Updated
Your technology needs to keep pace with the changes in telehealth. Using outdated billing software can lead to major headaches, as it may not include the latest CPT codes, modifiers, or place of service codes. This can result in automatic claim rejections and delayed payments. Ensure your software vendor provides regular updates and that your team is trained on how to use new features effectively. When your providers and staff are comfortable using the technology, it streamlines the entire process from documentation to submission. A well-managed system is fundamental to delivering reliable and efficient virtual care services and is a key part of effective practice management.
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Frequently Asked Questions
Do I have to use the new 2025 telehealth codes for all my patients? Not necessarily. While the new 98000-series codes are meant to standardize telehealth billing, not all insurance companies will adopt them right away. Some private payers may still require you to use the familiar method of a standard E/M code with a modifier like 95. The only way to be certain is to verify the requirements for each specific payer before submitting a claim.
What’s the most important thing to remember when billing Medicare for telehealth? The single most critical rule is that Medicare will not accept the new 2025 telehealth codes. For all Medicare patients, you must continue to use the standard in-person E/M codes (like 99213 or 99214) and append the correct modifier to show the service was virtual. Using modifier 95 for audio-video visits or 93 for audio-only calls is essential for getting your Medicare claims paid.
Should I bill based on the time I spent with the patient or the complexity of their issue? You have the option to choose either method, so you should select the one that best reflects the work you performed. If you had a long conversation that involved a lot of counseling but the medical decision-making was straightforward, billing based on time might be more appropriate. Conversely, if you made a complex diagnosis in a shorter visit, billing based on medical decision-making (MDM) would better capture the service’s value. Just be sure your documentation clearly supports whichever method you choose.
We keep getting telehealth claims denied. What’s the most common mistake practices make? The most frequent errors often come down to small but crucial details. A common pitfall is a mismatch between the code and the payer’s rules, such as using a new 2025 code for a Medicare claim. Other frequent mistakes include forgetting to add the necessary modifier (like 95 or GT), using an incorrect place of service code, or having documentation that doesn’t fully support the level of service billed. A thorough review process before submission can catch most of these issues.
It feels impossible to keep up with every payer’s rules. What’s the most effective way to manage this? You’re right, it’s a significant challenge. The most effective strategy is to be proactive and organized. Designate a point person or team to regularly check for updates from your top payers and government sources like CMS. Creating a simple reference guide for your staff that outlines the specific rules for each major insurer can also prevent confusion. For many practices, partnering with a dedicated billing service is the most efficient solution, as it places the responsibility of tracking these constant changes in the hands of experts.
