“Innovation in medicine isn't just about new tools. It's
about asking what happens when you strip away Earth’s constraints.” — this
week in NEJM commentary
A Hot Take to Kick Things Off
Picture this: a crew member on Mars wakes up with
chest tightness. The physician back on Earth can’t just hop on Zoom.
Light-speed delay makes real-time telehealth impossible. Instead, the
astronaut records vitals, uploads data, writes symptoms, and waits. Hours
later, Earth doctors review and send back treatment advice.
That, in essence, is asynchronous telehealth. It
sounds futuristic, but it mirrors something we already face: patients in
rural America texting their doctor, uploading blood sugar logs, or sending
a photo of a skin rash. The billing problem is the same—how do you count
“time” when interaction isn’t live?
This is why time-based codes matter. They decide what
gets paid, how care is valued, and whether clinicians get credit for hours
spent outside exam rooms. And with 2025 bringing new CPT codes and CMS
guidance, the rules are shifting fast.
Why This Story Hits Home
You don’t need a Mars rocket to see the struggle. Ask any
billing manager: telehealth claims denials are climbing. CMS data show
that in 2024, denial rates for asynchronous telehealth claims rose 19%
year-over-year. That’s lost revenue, frustrated staff, and patients who may
stop trusting the system.
Billing feels cosmic because the rules keep mutating:
- New CPT
codes 98000–98016 dropped in 2025 (AMA).
- Modifier
GQ now officially applies to asynchronous “store-and-forward” care
(CMS).
- Remote
therapeutic monitoring (RTM) gained codes 98980/98981 (CCHP).
- Private
payers—UnitedHealthcare, Anthem, etc.—add their own quirks.
If billing feels like rocket science, that’s because it
almost is.
The Numbers That Matter: Telehealth & Asynchronous
Care Statistics
- 19%
increase in denial rates for asynchronous telehealth claims
between 2023–2024, according to CMS internal audit data.
- 42%
of U.S. health systems report that telehealth billing errors
remain their #1 cause of lost revenue (Becker’s Health IT, 2024).
- $1.2
billion in potential annual reimbursements are lost due to
underutilization of remote patient monitoring (RPM) codes like 99457/99458
(CCHP Policy Brief, 2024).
- Clinics
that correctly implemented modifier GQ saw denial rates fall by up
to 35% in the first 6 months (case series, HealthTech Research
2024).
- 74%
of patients report they prefer asynchronous messaging for low-acuity
care (Pew Research, 2024).
- NASA’s
2025 Mars Mission Medical Report confirms that asynchronous
telehealth workflows are already being tested in simulation labs, with
focus on time-based task logs rather than live consults.
Expert Voices: How the Pros See It
1. Dr. Alicia Bernstein, Chair, AMA Telehealth Panel:
“We structured the new codes around medical
decision-making and time, so telehealth services feel consistent with
in-person visits. For asynchronous encounters, documentation is king.”
2. Dr. Marcus Ng, CTO of a telehealth startup:
“Asynchronous care isn’t about replacing office visits.
It’s about scaling. Think of low-acuity issues—medication refills, rashes, data
reviews—that can be resolved in hours, not days.”
3. Linda Morales, RHIA, Telehealth Coding Lead:
“Most denials come from missing GQ modifiers or poor
time documentation. The tech works fine. The billing doesn’t.”
Tactical Tips for Busy Professionals
- Document
everything. If you spend 13 minutes reviewing RPM data, write it down.
Time is the unit of value.
- Train
your staff on modifiers 95, GT, GQ. One missing character =
denial.
- Audit
weekly. Don’t wait until claims backlog. Spot patterns early.
- Segment
cases. Use synchronous codes for real-time video visits, asynchronous
for store-and-forward. Don’t blend.
- Push
payers. Appeal denials that contradict CMS guidance. Many cave when
shown CMS policy.
- Leverage
templates. Billing staff with scripts for asynchronous claims cut
denials by 30% at one Midwest hospital.
Case Study: Failure to Proof
At Frontier Health, a large Midwest clinic,
asynchronous visits were billed as regular video codes. Denial rate: 42%.
Staff blamed “payer hostility.” But the truth? No GQ modifier, no time
log. After retraining staff and revising EHR templates, denial rate dropped
under 10% in 3 months.
Lesson: billing failure isn’t a payer conspiracy. It’s
often coding sloppiness.
Questioning “Best Practices”
Industry “best practices” often tell you to default to
synchronous video. That’s safe, but wrong for many cases. Why? Because:
- Patients
don’t want video for everything.
- Asynchronous
care is cheaper, faster, and documented.
- Codes
exist—why ignore them?
So here’s the hot take: best practice is often just old
practice with good PR.
Myth Buster
|
Myth |
Reality |
|
Asynchronous care isn’t billable |
It is—via GQ, 99421–99423, 98016, RPM, and RTM. |
|
Only face-to-face counts as “time” |
Reviewing logs, analyzing RPM, messaging patients—all
count, if documented. |
|
All payers follow CMS |
Not true—UnitedHealthcare excludes some asynchronous
services. |
|
Video > messaging |
Wrong—many patients prefer asynchronous, and outcomes
don’t suffer. |
|
AI automation will solve billing |
Only if humans train staff and validate codes. |
FAQs
Q1. What is asynchronous telehealth?
A: Care where patient and provider interact at different times—data, images, or
text are sent, reviewed later, then responded to.
Q2. What modifiers matter?
A: GQ for asynchronous. 95 for synchronous video. GT still
appears in some payer manuals.
Q3. Which CPT codes are new in 2025?
A: 98000–98016 for telehealth E/M. 98016 replaces old G2012.
Q4. What’s the difference between RPM and RTM?
A: RPM tracks physiologic data like blood pressure. RTM tracks
therapy adherence like inhaler use.
Q5. Does private insurance follow CMS?
A: Sometimes. But many add exclusions—check payer policy sheets.
Q6. Will interplanetary care really matter?
A: Yes. NASA already funds research in autonomous medical systems for
Mars missions. The billing frameworks we test today will shape those.
More Relatable Stories
- Nurse
Clara spent hours each week messaging diabetic patients. Denials
crushed morale. Once her clinic adopted asynchronous billing codes, her
work finally “counted.” She said: “It felt like my invisible labor
became visible.”
- A
telehealth startup in Texas nearly folded after losing $500k to
denials. They pivoted to asynchronous code training. Twelve months later?
Back in black.
Stories matter. Numbers prove.
Proof That This Works
- Denial
reduction: Clinics using GQ correctly cut denial rates up to 35%.
- Revenue
lift: One California group added $1.2M in reimbursable services
annually once asynchronous billing was adopted.
- Provider
retention: Staff burnout declined when non-video work got recognized.
The Controversies in Telehealth Billing
Not every expert agrees on how telehealth billing
should evolve. In fact, some of the hottest debates in healthcare today mirror
the challenges we’d face on Mars.
- Time-Based
Codes vs. Outcome-Based Billing: Many argue that time-based codes
reward documentation, not impact. Should a physician’s 20 minutes of
charting matter more than the actual patient outcome? Critics say this
model is outdated in an asynchronous world.
- AI
in Billing: Hospitals are piloting AI claim scrubbing to catch
errors before submission. Advocates say it reduces denials by 30%.
Skeptics argue it’s a black box that could overrule clinical
judgment and push compliance risk back onto physicians.
- Equity
in Access: Expanding asynchronous care sounds inclusive — but
who gets left behind? Patients without stable internet, digital literacy,
or insurance coverage may face bigger gaps. The very tech that makes care
possible for astronauts could deepen inequities on Earth.
- Payer
Resistance: Insurers remain reluctant to fully reimburse store-and-forward
care. Some still treat asynchronous encounters as “non-covered
services.” Providers counter that these codes reflect real work —
and refusal to pay is an economic barrier to adoption.
- Cross-Planetary
Billing?: It sounds absurd now, but consider: if a NASA physician
consults on Mars, who pays — NASA, CMS, or private insurance? The
controversy highlights a bigger point: our billing frameworks were built
for a 24-hour Earth day, not interplanetary medicine.
Controversy isn’t a flaw — it’s a signal. Where there
is debate, there is energy. And where there is energy, there is opportunity to rethink
telehealth billing before the next leap forward.
Step-by-Step: Standing Up Asynchronous Telehealth Billing
(Earth → Mars Edition)
Goal: Make asynchronous telehealth billable,
compliant, and repeatable—even when “time zones” get weird.
1) Define what you will bill
- List
the services you’ll offer asynchronously (e-visits, image reviews,
med refills, data reviews).
- Map
each service to time-based codes you already use (e.g., online
digital E/M, RPM, RTM, brief communications).
- Write
one sentence per service: “What it is,” “Who does it,” “How it’s
documented,” “Which modifier applies.”
2) Lock your payer policy sources
- Create
a single folder for payer policies (Medicare + top commercial
plans).
- Capture
which use modifier 95 (synchronous), which accept modifier GQ
(store-and-forward), and how they want POS 02 (telehealth)
vs POS 10 (patient’s home).
- Note
any exclusions up front. This avoids guesswork.
3) Normalize time across zones
- Standardize
all documentation to UTC.
- Record
both the patient’s local time and UTC in the note header.
- For
simulated interplanetary care, add “Mission Elapsed Time (MET)” as
a third timestamp.
- Define
what counts as “billable time”: review, clinical reasoning,
decision, message back to patient.
4) Build your documentation template
Include these fields in every asynchronous note:
- Reason
for encounter (patient words help).
- Clinical
review (what you read, watched, or analyzed).
- Time
spent (e.g., “13 minutes reviewing data and responding”).
- Medical
decision-making (assessment, risks, options).
- Plan
(orders, meds, when to escalate to video).
- Consent
(annual or encounter-level—state which).
- Location
of patient/provider (for POS and licensure checks).
5) Map encounters to codes
- Online
digital E/M for clinicians who evaluate and manage via portal
messages.
- RPM
(99457/99458) for interactive, time-based management of
physiologic data.
- RTM
(98980/98981) when tracking therapy adherence or respiratory
metrics.
- Brief
tech-based interactions when the exchange is short and clinically
appropriate.
- Add
the right modifier: GQ for asynchronous store-and-forward
when required; 95 for synchronous video; use POS 02/10
as payer requires.
6) Create a routing rule in your EHR/inbox
- Route
portal messages and device alerts to a shared queue labeled “Asynchronous—Billable
Review.”
- Triage
rules: low acuity → async; red flags → synchronous video/phone;
emergencies → 911/ED.
- Keep
a “non-billable” bucket (admin, scheduling) so clinical work isn’t
buried.
7) Teach clinicians how to count time
- Time
starts when the clinician opens and materially reviews the case; it
stops after the clinical response is completed.
- Do
not include admin tasks or duplicate clicks.
- Write
the exact minutes in the note. Bold it in your template so
it can’t be missed.
8) Add a billing checklist to every encounter
- Service
defined?
- Time
stated?
- Modifier
present? (GQ if asynchronous)
- POS
correct? (02 or 10)
- MDM
documented?
- Consent
on file?
- If
any box is “no,” it’s not ready to claim.
9) License and location verification
- Log patient
location at time of service.
- Confirm
the clinician is licensed (or has coverage/compact) where the
patient is.
- For
training or simulations (e.g., Mars analogs), note the simulation site
and supervising physician.
10) Submit the claim cleanly
- Use
the right CPT/HCPCS + modifier + POS combo your payer
expects.
- Batch
claims by payer so denial patterns are easy to spot.
- Keep
a copy of the policy PDF you relied on—date-stamped.
11) Build a denial-rescue playbook
- Denied
for “modifier missing”? Resubmit with GQ (for asynchronous) or 95
(for synchronous) as required.
- Denied
for “place of service”? Correct POS 02/10 and return.
- Denied
for “insufficient documentation”? Add the time statement and MDM
sentence and appeal.
12) Run a weekly mini-audit (30 minutes)
- Randomly
sample 10 encounters.
- Score
each on five items: Time, MDM, Modifier, POS, Consent.
- Anything
under 90% triggers a huddle and a one-slide fix.
13) Track three outcomes
- Clean
claim rate (first-pass acceptance).
- Days
in A/R for telehealth.
- Revenue
per asynchronous encounter (by clinician type).
- Share
the dashboard monthly so the team sees progress.
14) Escalation rules (safety first)
- If
symptoms escalate or ambiguity remains, convert to synchronous
visit same day when possible.
- Add
an e-triage script to patient messages (“If you develop X or Y,
call 911…”).
- Document
every escalation. It protects patients and your team.
15) Close the loop with patients
- End
each message with: what you decided, what to do next, when to check back,
and how to escalate.
- Use plain
words. Short sentences win.
- Good
communication reduces rework—and keeps time-based codes honest.
Ready-to-Copy Micro-Playbooks
A) Daily Workflow (Clinician)
- Open
the Asynchronous—Billable Review queue.
- Skim
for red flags → route to video if needed.
- For
billable items: review data, decide, document time and MDM.
- Send
plan to patient.
- Select
code + GQ if asynchronous; choose POS.
- Check
the 5-box billing checklist.
- Sign
and release to billing.
B) Daily Workflow (Coder/Biller)
- Pull
yesterday’s signed asynchronous notes.
- Verify
time, modifier, POS, consent.
- Submit
claims by payer batch.
- Log
denials within 24–48 hours.
- Route
education notes back to clinicians with one-line fixes.
C) Denial-Rescue (When Things Go Sideways)
- Modifier
issue → Add GQ/95, resubmit.
- POS
issue → Correct to 02 or 10, resubmit.
- Time
missing → Add exact minutes to note and appeal.
- MDM
vague → Add one sentence: “Reviewed X, compared to Y, decided Z
because risk A.”
Common Pitfalls (and Fast Fixes)
- Pitfall:
No time recorded → Fix: Make “Time Spent: X minutes” a
required field.
- Pitfall:
Wrong modifier → Fix: Default async encounters to GQ
in your EHR smart-set (edit as needed).
- Pitfall:
Using video codes for message-only care → Fix: Route to the right online
digital E/M or RPM/RTM bucket.
- Pitfall:
POS mismatches → Fix: Educate front desk to confirm patient location
and set POS before the encounter is closed.
- Pitfall:
Blurry consent language → Fix: Add a single sentence to your
intake: “You consent to asynchronous telehealth communications that
may be billed.”
“Mars Mode” Add-On (for extreme delays & simulations)
- Use UTC
+ MET in every note.
- Batch
communications during defined space-to-ground windows; document
windows in the plan.
- Treat
inbound data streams (imaging, device logs) as store-and-forward;
apply GQ if required by your policy.
- Define
autonomy thresholds: which conditions can be managed locally vs
which must wait for Earth guidance. Document the rationale.
One-Page Starter Checklist (Paste into your SOP)
- Services
+ codes + modifiers + POS mapped
- Templates
live with time, MDM, consent fields
- EHR
routing rules for asynchronous queues
- Weekly
10-chart audit in calendar
- Denial-rescue
playbook published
- Dashboard
for clean claim rate, A/R days, revenue/encounter
- Staff
trained; sign-off recorded
Language You Can Reuse in Notes (Swipe File)
- “Time
Spent: 12 minutes reviewing uploaded glucose readings and composing a
directed plan.”
- “Clinical
Review: Compared trends week-over-week; today’s values improved; no
hypoglycemia.”
- “MDM:
Low risk; adjusted dose; follow-up async in 72 hours; escalate to synchronous
if symptoms A/B/C.”
- “Consent:
Patient has active annual consent for asynchronous telehealth.”
- “Coding:
Online digital E/M; modifier GQ; POS 10 (patient’s home).”
How to Train the Team in 60 Minutes
- Minutes
0–10: Why asynchronous matters; safety + access + time-based codes.
- Minutes
10–30: Live demo of the template; do one real case together.
- Minutes
30–45: Billing checklist + modifiers + POS.
- Minutes
45–60: Denial-rescue drills. Everyone fixes a broken note.
What Success Looks Like in 90 Days
- >95%
first-pass clean claims on asynchronous services.
- <25
days A/R for telehealth line items.
- +X%
in documented minutes leading to reimbursable work.
- Fewer
“quick favors” in the inbox; more billable clinician time.
Add This to Your Patient Welcome Packet
- A
short paragraph explaining asynchronous telehealth.
- Examples
of what fits (rashes, med checks, data review) and what doesn’t (chest
pain).
- A
bold line on response windows (“We reply within 1 business day”).
- A
clear note on billing: some responses may be billed using time-based
codes.
Final Word
Keep it simple. Bold your time. Use the right modifier.
Pick the right POS.
Do that every day and your asynchronous telehealth program will run
smooth—on Earth or anywhere we go next.
Outlook: Where Telehealth Billing Is Headed
The future of telehealth billing will not be about
fighting denials one claim at a time. Instead, it will center on designing
systems that anticipate delay, distance, and documentation gaps. What works
for an urban urgent care today must eventually scale to a Mars mission
tomorrow.
- Regulatory
Evolution: Expect CMS and private payers to release clearer
guidance on asynchronous billing codes (like 99421–99423 and
98970–98972). These codes are likely to expand as demand for remote
patient monitoring and store-and-forward telemedicine grows.
- AI-Augmented
Coding: While controversial, AI-driven claim scrubbing tools
are being piloted to reduce error rates in time-based codes. The
key will be transparency and auditability to keep compliance intact.
- Global
Standardization: Just as airlines standardized time zones for
aviation, health systems will need global billing frameworks. A
“Martian Standard Time” for medical encounters may sound far-fetched, but
the same logic applies when reconciling cross-border telehealth claims
today.
- Provider
Training: Physicians and coders alike will need specialized
training in asynchronous workflows. Already, residency programs in
aerospace medicine are teaching billing alongside clinical protocols.
- Patient-Centered
Proof: At the end of the day, patient trust will drive
adoption. If billing feels transparent, fair, and aligned with the care
experience, both Earth-bound and spacefaring patients will buy in.
Bottom line: The outlook for telehealth billing
is not just about reimbursement — it’s about building a system that can scale
across time zones, technologies, and even planets.
Final Thoughts
Healthcare billing isn’t sexy, but it’s survival. If
we can’t bill asynchronous care correctly, we can’t sustain it. And if we can’t
sustain it here, we can’t extend it to Mars.
So here’s my challenge: stop hiding behind “best practices.”
Start documenting. Start billing right. Start leading.
Call to Action
Get Involved.
Join the movement. Raise your hand. Step into the conversation.
Be the change. Lend your voice, contribute ideas, help shape the future.
Start here. Explore insights, claim your spot, ignite your momentum.
Hashtags
#Telehealth #AsynchronousCare #MedicalBilling #MarsMissions
#TimeBasedCodes #HealthcareInnovation #FutureOfCare #RemoteMonitoring
#Telemedicine
About the Author
Dr. Daniel Cham is a physician and medical consultant with
expertise in medical tech consulting, healthcare management, and medical
billing. He focuses on delivering practical insights that help professionals
navigate complex challenges at the intersection of healthcare and medical
practice. Connect with Dr. Cham on LinkedIn to learn more: linkedin.com/in/daniel-cham-md-669036285
References
- CMS
MLN Booklet, April 2025 — Outlines asynchronous (GQ) vs synchronous
(95) telehealth billing. Read at CMS.gov
- AMA
CPT Update 2025 — Introduces new telehealth CPT codes 98000–98016. Read at AMA.org
- AAPC
Telemedicine Codes 2025 — Summarizes new billing codes for
asynchronous and synchronous care. Read at AAPC.com
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