"Innovation is the ability to see change as an
opportunity – not a threat."
— Steve Jobs
Imagine this: Dr. Emily, a primary care physician in
Oakland, California, conducts a routine telehealth visit with a patient named
Mr. Johnson, who is managing chronic hypertension. During the consultation,
they discuss his recent blood pressure readings, adjust his medication, and
schedule a follow-up. Dr. Emily documents the encounter meticulously, using the
appropriate Evaluation and Management (E/M) CPT codes. However, when submitting
the claim, she faces unexpected denials from Medicare, citing incorrect coding
practices.
This scenario underscores the complexities and challenges
that healthcare providers face in telehealth billing. With the introduction of
new CPT codes and evolving compliance requirements in 2025, understanding the
nuances of telehealth billing has never been more critical.
Understanding the New CPT Codes for Telehealth in 2025
In 2025, the American Medical Association (AMA) introduced
new CPT codes to better capture telehealth services. These codes are designed
to differentiate between various types of telehealth interactions, including
synchronous audio-video and audio-only consultations. The new codes are as
follows:
- Synchronous
Audio-Video Consultations:
- 98000–98007:
For new and established patients, these codes correspond to the
traditional E/M codes (99202–99215) but are specifically for telehealth
encounters.
- Synchronous
Audio-Only Consultations:
- 98008–98015:
These codes replace the previous telephone codes (99441–99443) and are
intended for audio-only telehealth visits.
- Brief
Communication Technology-Based Services:
- 98016:
This code is for brief synchronous communications, such as a five- to
ten-minute medical discussion not related to a previous E/M service
within the last seven days or leading to one in the next 24 hours.
It's important to note that while these codes have been
adopted by the AMA, the Centers for Medicare & Medicaid Services (CMS) has
not recognized them for Medicare billing. Instead, CMS continues to require
providers to use the standard in-person E/M CPT codes (99202–99215) for
telehealth services, appending the appropriate modifiers to indicate the
modality used (e.g., modifier “95” for audio-video visits and modifier “93” for
audio-only visits).
Statistics relevant to telehealth billing and
reimbursement in 2025:
Telehealth Adoption and Usage
- 54%
of Americans have utilized telehealth services, with 1 in 6
having had four or more visits. Among users, 89% report satisfaction
with their most recent telehealth experience Dimensional Insight.
- 80%
adoption rate of telemedicine overall, making it the preferred channel
for prescription care and minor illness issues Market.us Media.
Reimbursement Rates and Financial Impact
- Medicare
reimbursement rates for telehealth services have seen adjustments,
with the conversion factor decreasing by 2.83% in 2025, impacting
overall payments to providers Waystar.
- CPT
code 98980, covering the initial 20 minutes of treatment time per
calendar month, has an average national payment rate of $50.14,
while CPT code 98981, covering each additional 20 minutes, averages
$39.14 healthrecoverysolutions.com.
Policy and Regulatory Developments
- CMS
has extended telehealth flexibilities for Medicare beneficiaries
through September 30, 2025, ensuring continued access to virtual
care services American Gastroenterological Association.
- Non-behavioral/mental
telehealth services in Medicare can be delivered using audio-only
communication platforms through September 30, 2025, with certain
conditions telehealth.hhs.gov.
These statistics highlight the growing adoption of
telehealth services, the financial considerations for providers, and the
evolving regulatory landscape. Incorporating these figures into your article
will provide readers with a comprehensive understanding of the current state of
telehealth billing and reimbursement.
Controversial Issues in Telehealth Billing
Telehealth has revolutionized healthcare, but the rapid
evolution of billing and coding practices has sparked several controversies
among providers, payers, and regulators.
1. Payment Parity Debate
- Some
states mandate that telehealth visits be reimbursed at the same rate as
in-person visits, but CMS and many commercial payers still maintain lower
reimbursement for audio-only visits.
- Controversy:
Are audio-only visits truly equivalent in quality to video or in-person
care, and should providers receive equal payment?
2. CMS Adoption of New CPT Codes
- The
AMA introduced new 2025 CPT codes for telehealth, yet CMS has
not officially adopted them.
- Debate:
Providers face confusion—should they follow AMA guidance or CMS rules?
Missteps can lead to denials or audits, creating tension between
regulatory compliance and clinical coding innovation.
3. Telehealth Across State Lines
- Cross-state
practice has exploded during the pandemic, but licensing
requirements remain complex.
- Controversy:
Should federal guidance allow more flexibility for telehealth licensure to
improve access, or is strict state oversight necessary to protect patient
safety?
4. Audio-Only vs. Video Visits
- Audio-only
visits are convenient and expand access, especially in rural or
underserved areas.
- Debate:
Some payers argue that audio-only visits are less comprehensive,
while providers claim they are clinically valuable. The disparity
in reimbursement raises ethical and operational questions.
5. Oversight and Audits
- Rapid
telehealth expansion has led to increased scrutiny by CMS and
private insurers.
- Controversy:
Are audits protecting patients and payers, or creating an unnecessary
burden on already strained providers?
Telehealth billing sits at the intersection of innovation, regulation, and
ethics, making it a hotbed for debate. Providers must balance compliance,
patient care quality, and financial sustainability while navigating these
ongoing controversies.
Recent News: Telehealth Billing and Policy Updates
1. Medicare Telehealth Flexibilities Extended Through
September 30, 2025
The Centers for Medicare & Medicaid Services (CMS) has
extended telehealth flexibilities for Medicare beneficiaries through September
30, 2025. This extension ensures continued access to virtual care services,
allowing patients to receive telehealth services from their homes without
geographic restrictions. This move reflects the ongoing commitment to expanding
access to care and adapting to the evolving healthcare needs of the population.
American College of Gastroenterology
2. AMA Introduces New CPT Codes for Telehealth Services
The American Medical Association (AMA) has introduced a new
set of CPT codes (98008–98015) for telehealth services, effective January 1,
2025. These codes are designed to report services delivered via audio-visual
and audio-only technology for both new and established patients. The new codes
align with the Evaluation and Management (E/M) guidelines, with service levels
based on medical decision-making or total time spent during the encounter. American Medical Association
3. Congressional Action Sought to Make Telehealth Changes
Permanent
A bipartisan bill in the U.S. House of Representatives aims
to protect Medicare patients' access to telehealth services beyond the current
flexibilities set to expire on September 30, 2025. The proposed legislation
seeks to make telehealth changes permanent, ensuring continued access to
virtual care for Medicare beneficiaries. American Medical Association
4. Massachusetts Health Leaders Advocate for Expanded
Telehealth Access
Massachusetts healthcare leaders are urging U.S. Health and
Human Services Secretary Robert F. Kennedy Jr. to expand telehealth services
and reduce regulatory burdens. In response to Kennedy's call for deregulatory
suggestions, the Massachusetts Health & Hospital Association (MHA)
submitted a proposal advocating for the standardization of prior authorization
processes, the revival of expired home health programs, and an expansion of
telehealth access. The MHA emphasized the importance of hospital-at-home services
for the state’s aging population. Axios
These recent developments underscore the dynamic nature of
telehealth billing and policy, highlighting the need for healthcare providers
to stay informed and adaptable in the face of ongoing changes.
Compliance Requirements and Challenges
Navigating the compliance landscape for telehealth billing
in 2025 involves understanding both federal and payer-specific requirements.
Key considerations include:
- Modality-Specific
Modifiers:
- As
mentioned, CMS requires the use of specific modifiers to indicate the
modality of the telehealth service. Incorrect use of these modifiers can
lead to claim denials.
- Place
of Service (POS) Codes:
- POS
codes indicate where the service was provided. For telehealth services,
POS 02 is used when the patient is not at home, and POS 10 is used when
the patient is at home. Accurate POS coding is essential for proper
reimbursement.
- Documentation
Standards:
- Comprehensive
documentation is crucial. Providers must ensure that all elements of the
E/M service are documented, including history, examination, medical
decision-making, and time spent. Inadequate documentation can result in
claim denials or audits.
- State-Specific
Regulations:
- Some
states have enacted laws that differ from federal guidelines, such as
payment parity laws requiring telehealth services to be reimbursed at the
same rate as in-person services. Providers must stay informed about
state-specific regulations to ensure compliance.
Expert Opinions on Telehealth Billing in 2025
To provide further insights, we consulted with three experts
in the field:
- Dr.
Sarah Thompson, MD, Family Medicine:
"The introduction of new CPT codes for telehealth services is a step forward, but the lack of recognition by CMS creates confusion. Providers must be diligent in using the correct E/M codes and modifiers to avoid claim denials." - John
Miller, CPC, Medical Coding Specialist:
"Accurate documentation and understanding of the new CPT codes are essential. Providers should invest in training for their staff to ensure compliance and reduce the risk of audits." - Lisa
Roberts, Healthcare Compliance Consultant:
"Staying informed about both federal and state regulations is crucial. Regularly reviewing payer policies and attending coding webinars can help providers navigate the evolving telehealth billing landscape."
Real-Life Case Study: Overcoming Billing Challenges
Consider the case of Dr. Michael, a cardiologist in San
Francisco, who faced multiple claim denials for telehealth consultations. After
a thorough review, it was discovered that his billing staff was using outdated
modifiers and incorrect POS codes. After retraining the team and implementing a
checklist for telehealth billing, Dr. Michael reported a significant decrease
in claim denials and improved reimbursement rates.
Frequently Asked Questions (FAQs)
- Q:
Why does CMS not recognize the new AMA CPT codes for telehealth?
- A:
CMS has not adopted the new codes due to statutory limitations and
continues to require the use of standard E/M codes for telehealth
services.
- Q:
What are the consequences of incorrect coding in telehealth billing?
- A:
Incorrect coding can lead to claim denials, delayed reimbursements, and
potential audits.
- Q:
How can providers stay updated on telehealth billing requirements?
- A:
Providers should regularly review CMS guidelines, attend coding webinars,
and consult with coding specialists to stay informed.
Legal Implications
1. Compliance with Federal and State Regulations
- Telehealth
billing must comply with CMS, HIPAA, and state telehealth laws.
- Violations
can result in denied claims, fines, or audits.
- Example:
Using an incorrect modifier or POS code could trigger Medicare audits.
2. Licensure Requirements
- Providers
must be licensed in the state where the patient is located at the
time of service.
- Cross-state
telehealth without proper licensure may lead to legal penalties.
3. Documentation and Recordkeeping
- Complete,
accurate documentation is legally required to substantiate medical
necessity and billing codes.
- Poor
documentation can jeopardize reimbursement and expose providers to
legal risk.
Practical Considerations
1. Technology Readiness
- Ensure
secure, HIPAA-compliant telehealth platforms (Zoom for Healthcare,
Doxy.me, Amwell).
- Test
video/audio connectivity and patient instructions to reduce failed
visits.
2. Staff Training and Workflow Integration
- Billing,
coding, and clinical staff must understand new CPT codes, modifiers,
and documentation requirements.
- Integrate
telehealth workflows into EHRs to automate reminders and coding
suggestions.
3. Payer Policies and Reimbursement Strategies
- Regularly
check payer-specific telehealth coverage, including audio-only,
behavioral health, and chronic care services.
- Develop
internal policies for claim submission, denial management, and appeals.
4. Risk Mitigation
- Use checklists
for telehealth billing to reduce errors.
- Track
claim denial trends and address root causes proactively.
Ethical Considerations
1. Patient Privacy and Confidentiality
- Maintain
strict adherence to HIPAA and state privacy laws.
- Avoid
unsecured platforms for consultations and ensure encrypted
communication.
2. Equity and Access
- Ensure
telehealth access for underserved populations, including those with
limited technology or connectivity.
- Consider
ethical implications of audio-only versus video visits, balancing
reimbursement with patient care quality.
3. Transparency and Informed Consent
- Inform
patients about billing practices, potential out-of-pocket costs, and
telehealth limitations.
- Document
patient consent for telehealth services, including audio-only visits
if applicable.
4. Clinical Responsibility
- Ensure
that telehealth visits meet the standard of care, even if physical
examination is limited.
- Avoid
compromising care for convenience or financial incentives.
Providers must navigate legal compliance, operational practicality, and
ethical responsibility simultaneously. Adhering to these principles ensures
that telehealth services remain high-quality, compliant, and
patient-centered, while protecting the practice from financial and legal
risks.
Myth Busters: Debunking Common Telehealth Billing
Misconceptions
- Myth:
New CPT codes for telehealth are universally accepted by all payers.
- Fact:
While the AMA has introduced new codes, CMS and many private payers have
not adopted them, requiring the use of standard E/M codes instead.
- Myth:
Telehealth services are reimbursed at the same rate as in-person visits.
- Fact:
Reimbursement rates for telehealth services can vary by payer and may be
subject to different policies and rates than in-person services.
- Myth:
Documentation requirements for telehealth are less stringent than for
in-person visits.
- Fact:
Documentation for telehealth services must meet the same standards as
in-person visits to ensure compliance and proper reimbursement.
Tools, Metrics, and Resources for Telehealth Billing
Success
1. Tools
EHR & Telehealth Platform Integration
- Epic,
Cerner, Athenahealth: Automate CPT code suggestions and documentation
capture for telehealth visits.
- Zoom
for Healthcare, Doxy.me, Amwell: HIPAA-compliant video platforms that
track visit duration and modality.
- AI-Assisted
Coding Tools:
- 3M
CodeFinder and Optum360 EncoderPro: Suggest accurate CPT codes
based on documentation.
- Reduces
errors and improves claim acceptance rates.
Claim Management & Compliance Software
- Kareo,
AdvancedMD, Experity: Integrated claim submission, denial tracking,
and reporting dashboards.
- Audit
Prep Tools: Track documentation compliance and identify missing
elements in telehealth claims.
2. Metrics to Track
Financial Metrics
- Claim
Denial Rate for Telehealth: Identify frequent coding errors or
payer-specific issues.
- Average
Reimbursement per Telehealth Visit: Compare audio-only vs. audio-video
vs. in-person rates.
- Revenue
Leakage: Monitor missed opportunities due to incorrect coding or
documentation gaps.
Operational Metrics
- Visit
Completion Rate: Track scheduled vs. completed telehealth visits.
- Average
Time per Visit: Helps in correct E/M code selection and documentation.
- Staff
Training Effectiveness: Measure coding accuracy before and after
training sessions.
Compliance Metrics
- Audit
Pass Rate: Percent of claims that meet CMS, AMA, and payer
documentation standards.
- Modifier
& POS Accuracy: Monitor correct usage of 95, 93 modifiers, and POS
02/10.
- State
Regulation Adherence: Track reimbursement compliance for telehealth
parity laws.
3. Resources for Staying Updated
Authoritative References (2025)
- MGMA
– Understanding the 2025 Telehealth CPT® Codes
Read more - AMA
– How the AMA Meets the Need for New Telehealth CPT Codes
Read more - Telehealth
Billing in 2025 – Updates and Practices
Read more
Government & Regulatory
- CMS
Telehealth Services: List of Covered Services
- HHS
Telehealth Policy Updates: Telehealth Policy Center
Professional Associations & Training
- AAPC
– 2025 Telemedicine Coding Updates: AAPC Resource
- MGMA
Coding Webinars & Checklists: MGMA 2025 Coding Updates
Analytics & Benchmarking
- Experity
Health Blog – What’s New in Telemedicine for 2025: Read More
- Blueprint
AI – Telehealth CPT Codes 2025: Read More
Use this combination of tools, metrics, and resources
to create a telehealth billing dashboard, optimize workflow, and ensure
compliance. Measuring outcomes and adjusting in real time can maximize
reimbursements and reduce claim denials.
Step-by-Step Guide: Navigating Telehealth Billing in 2025
Step 1: Understand the New CPT Codes
- Review
the 2025 CPT codes for telehealth:
- Synchronous
audio-video: 98000–98007
- Audio-only
visits: 98008–98015
- Brief
tech-based communication: 98016
- Keep
in mind that CMS still requires standard E/M codes (99202–99215)
with proper modifiers.
Step 2: Know the Required Modifiers and POS Codes
- Modifiers:
Use “95” for audio-video telehealth and “93” for audio-only visits.
- Place
of Service (POS):
- POS
02 → Patient not at home
- POS
10 → Patient at home
- Incorrect
usage can lead to denials or delayed reimbursement.
Step 3: Ensure Accurate Documentation
- Record
all E/M elements: history, examination, medical decision-making,
and time spent.
- Include
telehealth-specific notes, such as patient location, technology
used, and consent.
- Use
checklists or templates to standardize telehealth documentation.
Step 4: Review Payer Policies
- Confirm
state and commercial payer guidelines.
- Check
for payment parity laws and coverage limitations.
- Maintain
a reference guide for staff to avoid errors.
Step 5: Train Your Team
- Conduct
billing and coding training sessions.
- Update
coding manuals and EHR templates to reflect 2025 changes.
- Emphasize
audit preparedness and claim accuracy.
Step 6: Implement a Compliance and Quality Review
- Regularly
audit telehealth claims for accuracy.
- Track
denial rates and identify patterns.
- Review
regulatory updates from CMS, AMA, and state authorities.
Step 7: Leverage Technology
- Integrate
telehealth platforms with EHR to automate coding suggestions.
- Use analytics
dashboards to track reimbursement trends and gaps.
- Consider
AI tools for documentation support and error reduction.
Step 8: Stay Informed and Adapt
- Subscribe
to industry newsletters and webinars.
- Join
professional groups for peer insights.
- Be
ready to adjust workflows as telehealth policies evolve.
Final Thoughts
As telehealth continues to evolve, staying informed about
coding and compliance requirements is essential for healthcare providers. By
understanding the nuances of telehealth billing, implementing accurate coding
practices, and staying updated on regulatory changes, providers can navigate
the complexities of telehealth reimbursement and continue to deliver quality
care to their patients.
Future Outlook: The Evolution of Telehealth Billing
The telehealth landscape is evolving rapidly, and
billing practices must keep pace. Looking ahead, several trends are likely to
shape the future of telehealth reimbursement and compliance:
- Broader
Adoption of Standardized CPT Codes
While 2025 introduced new CPT codes for audio-video and audio-only telehealth visits, wider acceptance across CMS and commercial payers is expected in the next few years. Standardization will reduce confusion and streamline reimbursement processes. - Integration
of Advanced Digital Tools
Artificial intelligence, remote patient monitoring, and telehealth platforms will increasingly integrate with EHR systems, enabling automatic coding suggestions, documentation verification, and compliance checks. This will help reduce claim denials and audit risks. - State
and Federal Policy Alignment
As telehealth continues to grow, policymakers are moving toward greater consistency between federal and state regulations. This includes payment parity laws and clearer rules on cross-state telehealth practice. Providers who stay informed now will be better positioned to adapt quickly. - Expansion
of Telehealth Services Beyond Traditional Care
Telehealth is not limited to primary care or follow-ups; it is expanding into behavioral health, chronic disease management, and specialty care. As service offerings diversify, coding complexity will increase, requiring ongoing education for providers and billing staff. - Focus
on Quality and Outcomes-Based Reimbursement
Future telehealth reimbursement models will likely emphasize patient outcomes, quality metrics, and value-based care rather than simple service volume. Providers who track and report outcomes effectively will have a competitive advantage in reimbursement and payer negotiations.
Telehealth billing is no longer optional—it is a critical
component of modern healthcare operations. Staying proactive, educated, and
adaptable will position providers and organizations to capitalize on the
opportunities of virtual care while maintaining compliance and financial
sustainability.
Call to Action: Get Involved
Engage with the telehealth community by participating in
webinars, joining professional organizations, and sharing your experiences.
Together, we can shape the future of telehealth and ensure that billing
practices evolve to meet the needs of both providers and patients.
References:
- MGMA
– Understanding the 2025 Telehealth CPT® Codes
MGMA discusses new CPT codes for video and audio-only telehealth visits in 2025, including billing details and practical guidance.
Read more - AMA
– How the AMA Meets the Need for New Telehealth CPT Codes
AMA explains the rationale and implementation for the 2025 telehealth CPT code set, with breakdowns of codes for synchronous audio-video and audio-only visits, code ranges, documentation, and clinical requirements.
Read more - Telehealth
Billing in 2025 – Updates and Practices
A current overview of telehealth billing practices for 2025, covering CMS flexibility extensions, new AMA billing codes, commercial payer changes, and regulatory requirements for virtual and audio-only care.
Read more
You can also optionally add additional authoritative
resources for deeper reading:
- Key Telemedicine Updates for 2025 – The Rheumatologist
- AMA Releases CPT 2025 Code Set
- CMS Telehealth & Remote Patient Monitoring MLN Guide
Hashtags:
#TelehealthBilling #CPT2025 #MedicalCoding #HealthcareCompliance #Telemedicine
#MedicareBilling #EHR #HealthTech #MedicalProfessionals #HealthcareInnovation
About the Author
Dr. Daniel Cham is a physician and medical consultant with
expertise in medical technology, 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
Disclaimer:
This article is intended to provide an overview of the topic and does not
constitute legal or medical advice. Readers are encouraged to consult with
professionals in the relevant fields for specific guidance.
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