Telehealth Billing Guide: Rules, Tips, and Best Practices

I. Understanding the Core Concepts of Telehealth

What is Telehealth (and Telemedicine)?

• Telehealth encompasses a broad range of remote healthcare services, using technology to deliver care at a distance.
• Telemedicine services often refer specifically to clinical services provided remotely, while telehealth is a broader term that includes non-clinical services like provider training and administrative meetings.
• The need and use of telehealth greatly increased since the public health emergency.

Who Can Provide Telehealth Services?

• Qualified health professionals, as defined by their respective licensing boards and payer guidelines, are generally eligible to provide telehealth.
• Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) have specific billing considerations for telehealth, which we’ll cover later.
• Other providers, such as therapists, specialists, and even dietitians, may also participate in a patient's care via telehealth, depending on the service and payer policies.

Types of Telehealth Services:

1. Synchronous Telemedicine Service: This involves real-time interactive audio and video (audio-video) communication between the provider and patient. Think of it as a live video call.
2. Asynchronous Telecommunications System: Also known as “store-and-forward” technology. Information like recorded video, images, or patient data is collected and transmitted to the provider for review later.
3. Audio-Only Communication Technology: In certain situations, audio-only telehealth (e.g., a phone call) may be permissible. Coverage is often restricted to specific circumstances and patient populations.

A patient might utilize their patient portal to communicate with their physician and other healthcare professionals. Communication technology is the umbrella term that can be used to encompass all of these forms of communication.

Key Terminology:

• Originating Site: Where the patient is located during the telehealth visit. Restrictions have relaxed so that a patient’s home is now commonly accepted.
• Distant Site: Where the provider is located while delivering the service.
• Geographic location is now less of a restriction for many telehealth services than it used to be, expanding access to care.

II. CPT Codes for Telehealth Billing

What Are CPT Codes?

CPT (Current Procedural Terminology) codes are standardized codes used to describe medical, diagnostic, and surgical services. For telehealth, these codes help insurers understand the type of service provided during virtual care.

Common Telehealth CPT Codes

• 99441–99443: Telephone evaluation and management (E/M) services (often used for audio-only telehealth).
• 99212–99215: E/M services provided via video calls for established patients.
• 99421–99423: Online digital E/M services for patients. Check with individual payers for specifics.
• Remote Patient Monitoring (RPM): Includes codes such as 99453, 99454, 99457, 99458 for setup, monitoring, and management of patient data collected remotely.
• Professional and Management Services: These use different codes.

III. Place of Service (POS) Codes in Telehealth

What Are POS Codes?

POS codes indicate where the healthcare service was provided. For telehealth billing, they clarify that the service occurred remotely.

Key Telehealth POS Codes

• 10: Telehealth services provided in the patient’s home.
• 02: Telehealth services provided in a location other than the patient’s home (e.g., a clinic or other facility).

Choosing the Right POS Code

Using the correct POS code is crucial. Incorrect codes can lead to claim rejections or reduced reimbursements. Always review payer-specific guidelines.

IV. Modifier Usage for Telehealth Claims

What Are Billing Modifiers?

Modifiers are two-character codes added to CPT codes to provide extra details about the service or procedure. For telehealth, they help differentiate remote services from in-person care.

Common Telehealth Modifiers

• Modifier 95: Represents synchronous telemedicine services (real-time audio and video).
• Modifier GT: Indicates telehealth services via interactive audio and video communications (commonly used by Medicare).
• Modifier GQ: Used for asynchronous telecommunications (store-and-forward).

Always consult payer guidelines to ensure you’re using the most appropriate modifiers.

Tips for Accuracy

• Double-check payer requirements for modifier usage.
• Ensure the modifier aligns with both the CPT code and the POS code.
• Confirm if the service requires direct supervision.

V. Billing Medicare and Other Payers for Telehealth

Medicare Telehealth Services

Billing Medicare for telehealth visits requires following the latest CMS guidelines. Specific rules may apply to new versus established patients, as well as for services like initial inpatient consults or emergency department visits.

Private Payers

Private payers often have their own policies regarding telehealth reimbursement. Always check each payer’s guidelines.

Medicaid

Medicaid policies vary by state, so it is essential to verify your state’s specific requirements.

VI. Specific Billing Considerations for FQHCs and RHCs

Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) have unique billing mechanisms for telehealth. Instead of listing codes that may change, it’s best to refer readers to the appropriate CMS resources:

• CMS FQHC Center
• CMS RHC Center

Billing for professional and management services will have their own considerations.

VII. State-Specific Telehealth Billing Rules

Why Do They Matter?

State-specific rules dictate what telehealth services are covered, which providers can deliver care, patient consent requirements, and how claims should be submitted—including rules around prescribing controlled substances via telehealth.

Finding State Guidelines

Visit your state’s Medicaid website or consult resources like the Center for Connected Health Policy (CCHP) for the latest information.

Stay Updated

Since state regulations change frequently, review policy updates regularly to remain compliant.

VIII. Best Practices for Accurate Telehealth Billing

• Verify Patient Eligibility: Confirm the patient’s insurance coverage for virtual visits before service.
• Document Thoroughly: Include details such as the date, time, duration, modality (synchronous, asynchronous, audio-only), patient consent, and follow-up information.
• Stay Current on Payer Policies: Regularly review updates from Medicare, Medicaid, and private payers.
• Train Your Billing Staff: Ensure your billing team is knowledgeable about coding and claim submission.
• Use Billing Software: Consider a billing system that supports telehealth codes and modifiers to streamline processing.

IX. Common Telehealth Billing Errors and How to Avoid Them

1. Error 1: Incorrect CPT or POS Codes

   Solution: Double-check that your codes align with payer requirements.

2. Error 2: Missing Modifiers

   Solution: Ensure all claims include the appropriate modifiers.

3. Error 3: Lack of Documentation

   Solution: Keep comprehensive records detailing the telehealth visit.

4. Error 4: Failure to Verify Coverage

   Solution: Confirm the patient’s coverage and benefits prior to service.

5. Error 5: Incorrectly Billing for Audio-Only Services

   Solution: Use the appropriate codes and modifiers for audio-only services.

6. Error 6: Incorrectly Billing for Virtual Check-ins

   Solution: Verify the correct codes for virtual check-in services.

X. Future Trends in Telehealth Billing

• Expansion of Covered Services: More telehealth services will be covered.
• Improved Reimbursement Parity: Expect closer alignment between in-person and telehealth reimbursement.
• AI-Driven Billing Software: Emerging technologies will simplify coding and claims processing.

Staying informed about these trends will help your practice adapt to changes in telehealth policies.

XI. Resources for Telehealth Billing Compliance

• Centers for Medicare & Medicaid Services (CMS): Official guidelines for telehealth billing. CMS Telehealth Resource Page
• Center for Connected Health Policy (CCHP): A resource for state-by-state telehealth laws. CCHP National Telehealth Policy Resource Center
• Your State's Department of Health or Medicaid Website: For state-specific details.

XII. Simplify Your Telehealth Billing Today

Telehealth billing doesn’t have to be overwhelming. By following these best practices and staying informed about current rules and policies, you can streamline your billing process and maximize reimbursements for telehealth services.

If you need extra support, consider consulting with a trusted billing expert or leveraging specialized billing software. With the right tools and strategies in place, you can focus less on paperwork and more on providing exceptional patient care.