Telehealth Billing Compliance

May 2025

Telehealth billing expanded dramatically during and after the COVID-19 public health emergency, and the compliance landscape shifted with it. CMS made many PHE flexibilities permanent or extended them through legislation — but the rules differ significantly between Medicare, Medicaid, and commercial payers. Providers who built telehealth programs under emergency rules now face a patchwork of post-PHE requirements that vary by payer, service type, and patient location. Getting the billing right requires specific, current knowledge of each payer's telehealth policies.

The Telehealth Billing Landscape Post-PHE

The end of the COVID-19 public health emergency did not mean the end of expanded telehealth — but it did mean the end of uniform, blanket flexibility. Understanding what survived, what was extended, and what reverted is the starting point for any compliant telehealth billing program:

• During the PHE (2020–2023), CMS waived many telehealth restrictions — originating site requirements, geographic limits, and audio-only restrictions were largely suspended
• Many PHE flexibilities were extended through legislation (Consolidated Appropriations Acts) — providers must track which extensions apply and when they expire
• Key permanent changes post-PHE: telehealth can continue from the patient's home (no originating site requirement), mental health services can be delivered via telehealth without an in-person visit requirement (with certain exceptions starting in 2025)
• State Medicaid programs vary widely: some have permanent telehealth parity laws; others reverted to pre-PHE restrictions
• Commercial payers have their own telehealth policies that may differ from Medicare — check every payer contract

Place of Service Codes for Telehealth

Place of service (POS) codes are among the most consequential decisions in telehealth claim submission. An incorrect POS code does not just generate a denial — it generates the wrong reimbursement rate on claims that do pay. Key distinctions providers must know:

• POS 02: Telehealth provided in a location other than patient's home (e.g., originating site is a clinic or hospital)
• POS 10: Telehealth provided in patient's home — added by CMS to distinguish home-based telehealth from facility-based
• The difference matters: when POS 02 is billed, Medicare pays the facility rate (lower); POS 10 generates the non-facility (higher) rate for most services
• Behavioral health telehealth: POS 10 is typically appropriate when the patient receives the service from their home
• Always match the POS code to where the patient physically was during the visit — not where the provider was

Audio-Only Telehealth Billing

Audio-only (telephone) visits occupy a distinct and more restrictive category within telehealth billing. The rules for when audio-only is permitted, how it must be documented, and how it is reimbursed differ meaningfully from audio-video telehealth:

• Medicare: during the PHE, telephone E&M codes (99441–99443) were paid at the same rate as office E&M visits; post-PHE rates reverted to lower telephone visit rates
• Behavioral health exception: CMS allows audio-only telehealth for behavioral health services when the patient doesn't have access to video technology — specific documentation requirements apply
• MAT/OTP services: audio-only visits for substance use disorder counseling are permitted under certain CMS guidelines — a particularly important rule for behavioral health organizations
• Document the specific reason for audio-only delivery (patient lacks video capability, patient preference) — this protects the claim in audit
• Modifier GT (synchronous telehealth) and modifier 95 (synchronous real-time interactive telehealth) — check which modifier each payer requires; using the wrong modifier is a common source of denials

Behavioral Health Telehealth — Special Considerations

Mental and behavioral health services have some of the most favorable — and most closely scrutinized — telehealth billing provisions in the post-PHE environment. Organizations providing these services need particular familiarity with the applicable rules:

• CMS finalized that Medicare beneficiaries can receive mental health services via telehealth from home without first requiring an in-person visit (with annual in-person exception starting in 2025)
• Behavioral health telehealth billing codes include: 90834, 90837, 90847 (psychotherapy), 96130–96131 (psychological testing), H0038 (self-help/peer services), H2019 (therapeutic behavioral services)
• Substance use disorder (SUD) programs: telehealth for counseling and case management is broadly supported — document modality (video vs. audio-only) explicitly in the clinical record
• State-specific Medicaid telehealth parity laws may provide broader coverage than Medicare — always verify Medicaid telehealth policy by state before submitting claims
• Commercial behavioral health carve-outs may have separate telehealth policies from the medical plan — verify with each payer independently

Telehealth billing compliance requires ongoing vigilance as CMS, state Medicaid programs, and commercial payers continue to refine post-PHE policies. Providers that invest in coder education specific to telehealth, maintain updated payer matrices, and document telehealth modality and patient location on every encounter significantly reduce their exposure to denials and audit findings. The complexity is manageable — but it requires active attention to a rapidly changing regulatory environment.