Telehealth has become an indispensable part of modern healthcare, offering convenience and accessibility to patients and providers alike. For practices operating under a Fee-For-Service (FFS) model, navigating the complexities of telehealth billing is crucial for financial stability and accurate reimbursement. While the landscape is constantly evolving, especially with extensions of pandemic-era flexibilities, understanding the core rules is paramount.
This comprehensive guide will break down the top 10 telehealth billing rules for FFS, ensuring your practice is equipped to maximize revenue and minimize claim denials in 2025 and beyond.
The Shifting Sands of Telehealth Billing: A 2025 Snapshot
Before diving into the rules, it’s important to acknowledge the current environment. The Centers for Medicare & Medicaid Services (CMS) has extended many of its COVID-era telehealth flexibilities through September 30, 2025. This includes expanded eligible services, patient location allowances (including home), and broader provider eligibility.
However, a significant development for 2025 is the introduction of new telehealth-specific CPT codes (98000-98016) by the American Medical Association (AMA). While some commercial payers are adopting these, CMS, for the most part, continues to recommend using standard Evaluation and Management (E/M) CPT codes (99202-99215) with specific modifiers and Place of Service (POS) codes. This dual-track approach necessitates careful attention to payer-specific guidelines.
Now, let’s explore the essential rules for FFS telehealth billing:
1. Understand Payer-Specific Policies (The Golden Rule)
This cannot be stressed enough: always verify telehealth billing policies with each individual payer. While CMS guidelines often set a precedent, commercial insurers and state Medicaid programs may have their own unique requirements regarding covered services, eligible providers, allowed modalities, modifiers, and reimbursement rates.
- Actionable Tip: Create a detailed matrix for your most common payers, outlining their specific telehealth billing rules. Regularly check their websites and bulletins for updates.
2. Differentiate Between Synchronous and Asynchronous Services
Telehealth services can be delivered in two primary ways, each with distinct billing implications:
- Synchronous Telehealth: Real-time, interactive audio and video communication (e.g., live video consultations). Most commonly reimbursed.
- Asynchronous Telehealth (Store-and-Forward): Transmission of medical information (e.g., images, pre-recorded videos) for review at a later time, typically without real-time interaction. Reimbursement for asynchronous services is generally more limited and highly dependent on payer policies and state regulations.
- Actionable Tip: Ensure your documentation clearly indicates the modality used for each telehealth encounter.
3. Master CPT Codes for Telehealth Services
For FFS, accurate CPT coding is paramount. In 2025:
- For Medicare (and many others): Continue to use the standard in-person E/M CPT codes (e.g., 99202-99215) for synchronous audio-video visits.
- For Commercial Payers (and potentially some future CMS changes): Be aware of the new AMA-created telehealth CPT codes (98000-98016). Some payers may require or prefer these.
- For Audio-Only Services: While many temporary flexibilities for audio-only services remain through September 30, 2025, specifically for non-behavioral/mental health services under Medicare, new AMA codes (98008-98015) exist for these. For Medicare, you’ll still append modifier “93” to the standard E/M codes.
- Actionable Tip: Stay updated on CMS announcements and individual payer communications regarding code adoption and requirements.
4. Apply Appropriate Modifiers
Modifiers provide additional information about a service. For telehealth, key modifiers include:
- Modifier 95: Used for synchronous telemedicine services (audio and video) when billing with standard E/M codes.
- Modifier 93: Used for audio-only telehealth services (Medicare-specific for E/M codes).
- Modifier GT: Previously used, now largely replaced by Modifier 95 for interactive audio-video. (Less common in 2025 but good to be aware of historical context).
- Actionable Tip: Incorrect modifier usage is a common cause of denials. Double-check modifier requirements for each payer and service.
5. Utilize Correct Place of Service (POS) Codes
The POS code indicates where the service was furnished. For telehealth:
- POS 02: Used when the telehealth service is provided from a location other than the patient’s home (e.g., the provider’s office, clinic).
- POS 10: Used when the telehealth service is provided to a patient in their home.
The correct POS code affects reimbursement, as some payers may differentiate rates based on the patient’s location.
- Actionable Tip: Accurately document the patient’s location at the time of service to ensure the correct POS code is applied.
6. Verify Patient Eligibility and Benefits
Before rendering telehealth services, always confirm the patient’s insurance eligibility and benefits for telehealth. This includes:
- Telehealth Coverage: Does their plan cover telehealth services for the specific type of service being provided?
- Cost-Sharing: What are the patient’s co-pays, deductibles, or co-insurance for telehealth?
- Network Requirements: Is your provider in-network for telehealth services?
- Actionable Tip: Implement a robust pre-visit verification process to avoid surprises and ensure patient financial responsibility is understood.
7. Maintain Thorough Documentation
Documentation for telehealth visits should be as comprehensive as for in-person visits. Key elements to include:
- Date and Time of Service: Clear record of when the service occurred.
- Modality Used: Specify if it was audio-video or audio-only.
- Patient and Provider Locations: Document where both parties were located.
- Medical Necessity: Justify why telehealth was medically appropriate for the encounter.
- Informed Consent: Document that the patient provided informed consent for telehealth services.
- Encounter Details: Standard SOAP (Subjective, Objective, Assessment, Plan) notes, just like an in-person visit.
- Actionable Tip: Standardize your electronic health record (EHR) templates to capture all necessary telehealth documentation fields.
8. Understand Geographic and Originating Site Restrictions (Post-PHE)
While many geographic and originating site restrictions were waived during the Public Health Emergency (PHE), these waivers are set to expire. Post-September 30, 2025 (unless further extended), Medicare’s pre-pandemic rules may re-emerge, which often required patients to be in specific rural or underserved areas and at approved originating sites (e.g., a clinic, hospital) to receive telehealth.
- Actionable Tip: Monitor legislative and regulatory updates closely. Have a contingency plan for a potential return to pre-PHE restrictions. The Medicare Telehealth Payment Eligibility Analyzer can be a helpful tool.
9. Be Aware of Payment Parity
Payment parity refers to policies that require insurers to reimburse telehealth services at the same rate as comparable in-person services. While many payers adopted payment parity during the pandemic, it’s not universally guaranteed post-PHE. Some payers may begin to differentiate reimbursement rates for telehealth.
- Actionable Tip: Review your payer contracts and fee schedules to understand their current and future stances on telehealth payment parity.
10. Stay Informed and Adapt
The telehealth landscape is dynamic. New technologies, evolving patient expectations, and ongoing legislative debates mean that telehealth billing rules can change rapidly.
- Actionable Tip: Subscribe to updates from CMS, your state’s Medicaid agency, professional organizations (e.g., AMA, HIMSS), and industry news outlets. Consider investing in a robust medical billing software that can adapt to changing regulations.
Common Telehealth Billing Errors to Avoid
- Incorrect Modifier Usage: As mentioned, a common pitfall. Always double-check.
- Insufficient Documentation: Lack of detail can lead to denials and audits.
- Billing for Non-Covered Services: Ensure the service is eligible for telehealth reimbursement by the specific payer.
- Outdated Information: Relying on old policies can lead to significant claim rejections.
- Lack of Patient Consent: Essential for legal and compliance reasons.
Conclusion
Navigating telehealth billing in a Fee-For-Service model requires diligence and a proactive approach. By understanding the evolving regulatory landscape, mastering CPT codes and modifiers, maintaining meticulous documentation, and staying informed about payer-specific policies, your practice can optimize its telehealth billing processes. This not only ensures proper reimbursement but also supports the continued growth and accessibility of telehealth services, ultimately benefiting both your practice and your patients. The future of healthcare is undeniably linked to virtual care, and robust billing practices are the backbone of its sustainable success.