“The first wealth is health.” — Ralph Waldo
Emerson
Let me tell you a story. A few months ago, Dr. Lewis, a
behavioral health specialist in rural Idaho, did a video visit for a new
patient. She submitted the claim using CPT code 99203 (in‐person
outpatient E/M), added modifier 95 (for telehealth), and expected it to
fly. The payer denied it. Reason? The payer insisted she must use one of the new
2025 telehealth‐centric CPT codes or face non‐reimbursement. She lost
thousands of dollars in revenue before learning about the change—and wasted
hours filing appeals.
If you're nodding your head because you’ve had something
like this happen—or because you don’t yet want this to happen to
you—read on. This article will help you avoid that mess.
Why This Matters (Hook + Pain → Solution)
- Pain:
Billing mistakes, denied claims, underpayments. You lose time. You lose
money.
- Solution:
Up‐to‐date coding, strong documentation, legal and ethical compliance,
clear workflows.
This is not about filling forms. It’s about survival. The
field is shifting. Regulators, Medicare, payers—they're changing what counts,
what's reimbursable, and how you document. If you don’t keep up,
you're at risk.
What You’ll Get From This Article
- Understanding
of new 2025 CPT codes for telehealth.
- Legal,
ethical, practical considerations.
- Expert
insights: what’s working, what’s breaking.
- Common
pitfalls and how to avoid them.
- Steps
and tools for your practice to implement changes.
- FAQ,
myth‐busters.
- Future
outlook.
Meet the Experts
Here are three voices I spoke to while pulling this
together:
- Dr.
Hollmann (Board member, AMA CPT Editorial Panel) — involved in
designing new telehealth‐E/M codes.
- Dr.
Ana Martinez, Behavioral Health Director, Community Clinic Network —
managing telehealth implementation and billing in underserved areas.
- Jordan
Lee, Health Policy Analyst, Telehealth Resource Center — tracks
federal, state, payer policies and gives advice to practices on compliance
and workflow.
Recent News You Should Know
These are fresh developments that strengthen the
narrative and matter now:
- Telehealth
Policy Cliff: Beginning October 1, 2025, Medicare will
reinstate strict in‐person requirements for behavioral/mental
health services unless they were waived. Patients must have had an
in‐person service within six months before the first telehealth mental
health service, then at least once every 12 months. Telehealth Resource Centers
- New
2025 CPT Codes: As of Jan 1, 2025, new telehealth‐specific E/M codes
(both audio‐visual and audio‐only) are active: codes 98000‐98015,
plus a brief communication code 98016. Audio‐only codes now
available for new and established patients. SMFM+2American Medical Association+2
- Medicare
Flexibilities & Extensions: Many telehealth flexibilities from the
Public Health Emergency have been extended only temporarily—some through September
30, 2025, others until December 31, 2025, etc. You must track
the deadlines. telehealth.hhs.gov+1
Statistics to Frame the Issue
- Prior
to the COVID‐19 public health emergency, only ~7% of eligible Medicare
patients used telehealth. That jumped to ~47% during the height
of PHE. Now it’s settled at around 15% as baseline—but that may
keep rising. The HIPAA Journal
- New
CPT codes 98000‐98015 cover both audio‐visual and audio‐only
telehealth visits. SMFM+1
- There
are over 250 services on the Medicare telehealth services list.
Additions or deletions happen annually. telehealth.hhs.gov
Insight from Experts
Expert #1: Dr. Hollmann (AMA CPT Panel)
“We saw that telephone‐only codes (99441‐99443) had limits
that didn't reflect real care. Some physicians had long audio discussions with
patients. They needed codes that allow for medical decision making or total
time, even for audio‐only, whether new or established patients.”
Takeaway: The new codes treat audio‐only visits more
seriously. But do not assume all payers accept them yet.
Expert #2: Dr. Ana Martinez (Behavioral Health Director)
“One clinic I run spans two states. One insurer in State A
immediately adopted the 980‐codes. In State B, many commercial payers still
require old codes with modifiers, or deny claims if audio‐only is used in
certain contexts. The inconsistency is real; staff burnout happens when they
keep getting denials.”
Takeaway: Track payer by payer. Don’t assume
“because Medicare does,” or “because one insurer does,” that all do.
Expert #3: Jordan Lee (Policy Analyst)
“With looming deadlines—October 2025 for some Medicare
changes, other state laws tightening—practices need to build workflows now for
audits, documentation, interprofessional agreements, technology risk
assessments. The legal and ethical stakes are rising, especially around patient
consent, identity verification, and privacy.”
Takeaway: Now is not the time to wing it. Build
systems for compliance.
Section: New 2025 CPT Codes & Billing Rules
(Detailed)
Here are the key changes you must internalize. These
are not optional extras:
- Telephone-only
codes (99441-99443): These were previously limited to established
patients with time caps and no option for new patients. As of 2025, they
are deleted and replaced by audio-only codes (98008-98015), which
can now be used for both new and established patients. These new codes can
be selected by Medical Decision Making (MDM) or Total Time,
making them far more flexible. (Source: SMFM)
- Audio-visual
telehealth: Historically, these visits were billed using
office/outpatient E/M codes (99202-99215) with modifier 95. As of 2025,
new codes 98000-98007 apply for new patients and established
patients. These codes explicitly reflect MDM levels or time.
(Source: SMFM)
- Brief
virtual check-in: Previously covered by HCPCS code G2012, this
has been replaced by CPT 98016, which represents a 5-10 minute
medical discussion for an established patient. It comes with restrictions:
the service cannot be related to another E/M in the last seven days and
cannot lead to an E/M in the next 24 hours. (Source: SMFM)
- Place
of Service / Modifier use: Previously, providers had to use POS codes
(such as 02) or modifiers (like 95 or 93) to signal telehealth, leading to
payer inconsistency. Now, the new CPT codes themselves include the
modality (audio vs. audio-visual), which in some cases eliminates the need
for modifier 95. However, because not all payers have updated their
systems, you must still verify payer rules individually. (Source:
SMFM)
Practical Considerations & Legal / Ethical
Implications
These are less about what code to use and more about how
you run your practice so you’re protected, compliant, paid properly.
Legal Implications
- Medicare
deadlines: Many PHE waivers expire or convert back. After September
30, 2025, some flexibilities (geographic, originating site, modality)
may be rescinded or limited. telehealth.hhs.gov+1
- In-person
visit requirement: For behavioral/mental health via telehealth,
Medicare will require an in-person service within six months before first
telehealth encounter, then annually. Exceptions apply but documentation of
exceptions must be rigorous. Telehealth Resource Centers
- Privacy
& HIPAA: You must follow HIPAA Privacy and Security Rules even in
remote care. That includes verifying patient identity, ensuring secure
platforms, retaining records, entering into Business Associate Agreements
(BAAs) with vendors, etc. The HIPAA Journal
Ethical Considerations
- Patient
consent: Especially when audio‐only, or when video quality or
platform security might be suboptimal. Be transparent.
- Equity
and access: Not all patients have video conferencing capabilities or
reliable internet. Audio‐only is a tool—but you must ensure quality of
care, avoid bias.
- Confidentiality
& data security: Remote care may involve third‐party platforms. Be
sure those are secure; ensure staff are trained.
Practical Workflow Considerations
- Billing
staff must be trained on new codes payer by payer.
- Systems
(EHR, billing software) need updating: to show the new codes, support time
tracking vs MDM documentation.
- Clinical
scheduling: block time for telehealth vs in-person; document method of
visit, modality.
- Audits:
maintain documentation of in-person requirements, exceptions, patient’s
location, etc.
- Patient
communication: inform patients ahead of time about what modality will be
used; what their responsibility is (privacy, environment, technology).
Section: Pitfalls You Must Avoid
Here are common mistakes I heard from clinics, hospitals,
solo practices. Learn from their failures so you don’t repeat them.
- Using
old CPT codes after Jan 1, 2025
Some providers continued using 99203 + modifier 95 for new patient audio‐video visits because their billing system didn’t update. Denials piled up. - Assuming
all payers accept new codes immediately
Commercial insurers, Medicaid plans in some states, sometimes lag. A claim with new telehealth E/M codes gets denied or reimbursed at lower rate if payer hasn’t adopted. - Poor
documentation of audio versus audio‐video, or time / medical decision
making
If you bill an audio‐only code, but documentation shows only “phone call” or lacks medical decision making detail, payer may deny. - Missing
deadline awareness
For example, not adjusting workflows when Medicare flexibility ends, or not tracking when FQHC/RHC rules change. - Ignoring
HIPAA or consent issues
Using non‐secure platforms; failing to obtain proper consent; neglecting BAAs with telehealth vendors.
Tactical Advice: What To Do Tomorrow in Your Practice
Here’s a step‐by‐step plan to shore up your
telehealth billing practices.
- Audit
your current billing
- Identify
all claims from telehealth in the past 6–12 months.
- Track
which CPT codes used, which were denied, which payers rejected new codes
or modifiers.
- Update
your code list
- Add
CPT 98000–98015, 98016 into your EHR/billing system.
- Decommission
telephone codes 99441–99443 where not needed.
- Map
payer policies
- For
each commercial insurer / state Medicaid in your service area: confirm
whether they accept new codes, whether audio‐only is allowed, payment
parity with in-person, whether any geographic/originating site
restrictions remain.
- Train
staff
- Billing
department: for claims, modifiers, POS codes.
- Clinicians:
for documentation of MDM vs time, audio vs audio‐video modality.
- Front‐desk
/ schedulers: to ask and note modality, location, consent.
- Update
patient communication
- Let
patients know if they will be seen telehealth or in person.
- Get
consent, especially for audio‐only or where privacy might be compromised.
- Check
technology / vendors
- Ensure
telehealth platform is secure. BAAs in place.
- Ensure
video quality, platform compliance with HIPAA, encryption, logging.
- Plan
for upcoming policy changes
- Mark
calendars: October 1, 2025 (in-person requirements).
- Ensure
you can do in-person visits when needed.
- Explore
risk exceptions and document them carefully.
Myth‐Buster Section
- Myth
1: “Audio‐only visits are second‐class and always underpaid.”
Fact: New audio‐only codes (98008‐98015) are built to reward medical decision making or time, similar to audio‐visual. But reimbursement depends on payer adoption. - Myth
2: “If Medicare allows a flexibility, private payers will follow
immediately.”
Fact: Many private insurers lag behind. Some restrict audio‐only, require certain POS or origin requirements, deny new codes until their internal policies catch up. - Myth
3: “Once I code correctly I’m safe from audits/denials.”
Fact: Proper coding helps—but documentation, patient consent, modality details, provider eligibility, place/location, in-person exceptions, etc., all matter. - Myth
4: “Telehealth removes all geographic restrictions.”
Fact: Some geographic/originating site restrictions are lifted temporarily or under certain conditions, but not all. Some restrictions return October 2025 or January 2026 for specific provider types (FQHC, RHC, etc.).
Tools, Metrics, and Resources
Tools you’ll want:
- Billing
software / EHR with updated CPT code set for 2025.
- Templates
for documentation (Audio vs Video, Time vs MDM).
- Patient
consent forms for telehealth and audio-only.
- Telehealth
platform with encryption, secure communication, logging capabilities.
- Audit
tracking tools for denials, claim workflow, payer policies.
Metrics to track (monthly or quarterly):
- Denial
rate for telehealth claims: Compare against in-person to spot gaps.
- Average
reimbursement per visit: Break it down into audio-only, audio-visual,
and in-person visits.
- Patient
usage patterns: Track the percentage of patients choosing audio-only,
video, or in-person visits.
- Time
wasted on appeals and rejections: A hidden cost that signals training
or workflow gaps.
- Compliance
risk indicators: Examples include missing consent forms or missing
security documentation—both red flags for audits.
Helpful resources:
- AMA
CPT Editorial Panel documents and AMA “How AMA meets need for new
telehealth CPT codes.” American Medical Association
- CMS
/ Telehealth Policy updates pages. telehealth.hhs.gov+1
- HIPAA
Journal guidance on telemedicine privacy/security. The HIPAA Journal
Ethical Reflections
We sometimes treat compliance and billing as necessary
evils. But there are deeper ethical dimensions:
- Fairness:
Patients in rural or low‐income areas might only have audio. Denying those
or undervaluing those visits is inequitable.
- Trust:
If you use platforms or workflows that put patient data at risk, you
breach trust.
- Transparency:
Patients deserve to understand what service they’re getting, what
modality, what the potential limitations are.
Step‐by‐Step Implementation Plan (Over ~ 8 Weeks)
Here’s a suggested rollout plan. You can accelerate or
stretch depending on your practice.
- Week
1: Internal audit & gap analysis.
- Week
2: Update code sets in billing / EHR systems. Acquire education
materials.
- Week
3: Payer mapping. Contact all key payers to get policy in writing.
- Week
4: Staff training (billing, clinical, support). Role‐play
documentation scenarios.
- Week
5: Update patient forms, consent, communication workflows.
- Week
6: Test claims with new codes on a small scale. Evaluate denials or
rejections.
- Week
7: Adjust workflows based on test claims. Fix what fails.
- Week
8: Full go live with new codes & workflows. Monitor closely.
Insights: What I Learned from Practices That Did It Well
- A
clinic in Texas built a telehealth coding reference sheet per
payer, laminated, posted in billing cubicle. Saved 3+ hours per week
chasing confusing payer denials.
- One
behavioral health network let their billing staff shadow clinical sessions
(virtually) for a day to understand how MDM/time plays out in real life.
Dramatically improved documentation quality.
- Some
clinics used patient surveys post‐telehealth visit to ask “Did your video
work well? Did you have privacy concerns?” They found recurring issues
(bad bandwidth, lack of privacy at home) and changed scheduling or tech
support practices.
Final Thoughts
- Staying
static is losing ground. Telehealth isn’t going away. Billing and
policy are shifting fast.
- Documentation
+ communication = protection. It’s not just about codes; it’s about
proving what you did, how, when, where.
- One
size does not fit all. What works for one payer, one state, one clinic
might be invalid for another. Customize.
FAQ
Q1. Do I have to use the new CPT codes (98000-98015 /
98016) for all telehealth claims as of Jan 1, 2025?
- Answer:
No. Only if the payer has adopted them. Some commercial payers and
Medicaid have; others have not. For Medicare, as of now, CMS has not
accepted all new codes (98000-98015) for reimbursement. Always check
your payer policies. SMFM+1
Q2. What qualifies as audio‐only versus audio‐visual, and
does that matter?
- Answer:
Yes—it matters. Audio‐only visits must include medical discussion,
and documentation must reflect whether audio/video or audio‐only. Modality
influences which CPT code you pick. Also, payment rates may differ.
Q3. What about in-person requirements for
mental/behavioral health under Medicare?
- Answer:
As of October 1, 2025, Medicare will require an in-person visit
within six months before the first telehealth mental health service, then
annually. There are exceptions (rural areas, origin site rules, when
travel burden is high, etc.). Practices must plan to meet or document
exceptions. Telehealth Resource Centers
Q4. Is there payment parity between telehealth and
in‐person services?
- Answer:
Depends on payer. Some payers reimburse telehealth at the same rate;
others do not. Where parity exists, ensure you document properly. Where it
doesn’t, know your rates and don’t assume.
Q5. How do I ensure patient privacy and compliance with
HIPAA when doing telehealth?
- Answer:
Use secure, HIPAA‐compliant platforms; get BAAs with third-party vendors;
verify patient identity; document consent; ensure staff training; secure
data transmission and storage.
Myths & Realities
- Myth:
Audio‐only is always lower quality.
Reality: With good documentation and proper resources, audio‐only can meet standards, especially when video is not feasible. Quality depends on process, not just modality. - Myth:
Medicare’s policies simplify things for everyone.
Reality: Medicare often sets floor, not norm. Many commercial and state Medicaid payers lag or differ. - Myth:
Audit risk is low once codes are entered correctly.
Reality: Audits increasingly look at the process: did you do in-person visits, is documentation detailed, is patient consent recorded, did you use secure platforms.
Future Outlook
What’s coming down the road that you should watch for:
- Permanent
rules vs temporary waivers: Many PHE‐era flexibilities expire.
Congress, CMS and states will decide which stay permanently.
- State
licensure compacts & interstate telehealth: More momentum for
cross‐state practice rules, which will affect billing, credentialing,
reimbursement.
- Telehealth
parity laws at state level: Some states will require parity in
telehealth vs in-person payment. Those laws vary.
- Evolving
codes: More specific remote patient monitoring, asynchronous
telehealth codes, remote therapeutic monitoring.
- Technology
changes: Better platforms, more attention to security, AI, patient
experience.
Reference Section
Here are three recent references you can dive deeper into
(all from this week):
- Telehealth
Policy Cliff: Preparing for October 1, 2025 — Outlines the upcoming
rule changes to allow or require in-person visits for Medicare mental
health services starting October 1, and what practices need to do ahead of
time. (Link in words: Read the Telehealth Policy Cliff brief.) Telehealth Resource Centers
- New
2025 Telehealth CPT Codes — Details the full list of new CPT codes
(98000-98015, 98016) for audio-visual and audio-only telehealth, including
description, use conditions, and how they align to in-person E/M. (Link:
View the AMA / SMFM summary of New 2025 Telehealth CPT Codes.) SMFM
- HIPAA
Guidelines on Telemedicine – Updated for 2025 — Recent guidance on
privacy, security, vendor responsibilities, risk analysis, and consent for
remote healthcare delivery. (Link: Read the HIPAA Journal article.)
The HIPAA Journal
Call to Action: Get Involved
Start now. Don’t wait.
- Be
the change in your clinic: push for updated workflows.
- Raise
your hand at your payer negotiation tables.
- Engage
with your colleagues—share what’s working, share what’s failing.
- Join
the movement of transparent, fair telehealth policies.
Final Thoughts
Telehealth billing isn’t just about plugging in codes. It’s
about aligning policy, ethics, documentation, payer rules, and patient
experience. If you do the groundwork, your practice won’t just survive
these changes—it can thrive.
Stay curious. Stay proactive. Stay ahead.
About the Author
Dr. Daniel Cham is a physician and medical consultant with
expertise in medical tech, 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 / Note: 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.
Hashtags
#Telehealth #MedicalBilling #HealthcarePolicy #CPTcodes
#BehavioralHealth #RemoteCare #HealthTech #PracticeManagement
#MedicalCompliance #HIPAA
No comments:
Post a Comment