If you’re like most doctors, you’ve probably stared at your EHR screen at the end of a long day, wondering if your telehealth notes are complete or if that one missing detail could cost you a claim. Telehealth isn’t new anymore, but the rules keep shifting. New CPT codes, updated documentation requirements, and temporary policy changes make billing feel like walking on a tightrope. One slip, and claims get denied.
This guide breaks it down simply. By the end, you’ll know exactly what to document, which codes to use, and how to keep your telehealth billing smooth and compliant in 2025.
Why Documentation Can’t Be Skipped
Let’s get real: just because the patient is on a video call doesn’t mean the rules for documentation go away. In fact, thorough records are more important than ever. They protect your practice, justify your billing, and make audits far less stressful.
Here’s what you need for every telehealth visit:
- Patient consent for telehealth
- Location of both the patient and provider
- Mode of service (audio-video vs. audio-only)
- Medical necessity
- Complete clinical notes
Yes, it looks like a lot, but these aren’t arbitrary boxes to tick. Payers, including Medicare, require them to be explicitly documented. That includes the technology used and, in some cases, why telemedicine was chosen over an in-person visit.
For mental health or behavioral health visits, audio-only is still allowed as long as the patient’s home is listed as the site of care. CMS has made this permanent, recognizing that not all patients have reliable video access but still need care.
Some federal rules have been temporarily loosened, too. Telehealth is allowed for hospice recertification, acute hospital care at home, and follow-up visits in inpatient or nursing facilities through September 30, 2025. These flexibilities are meant to keep patients safe while allowing you to provide care remotely.
CPT Codes You Need to Know
CPT codes are the backbone of any billing process. For telehealth, 2025 brings some big updates. Codes 98000–98007 now cover synchronous (live) audio-video telemedicine visits. They mirror the in-person E/M rules, meaning you pick a code based on Medical Decision Making (MDM) or total time spent with the patient.
Here’s a quick guide for new patients:
- 98000: Straightforward decision-making, 15–29 minutes
- 98001: Low decision-making, 30–44 minutes
- 98002: Moderate decision-making, 45–59 minutes
- 98003: High decision-making, 60–74 minutes
For extended visits, you can use add-on code 99417 for non-Medicare patients or G2212 for Medicare.
Established patients have their own set: 98008–98011 and 98012–98015, covering audio-only and audio-video visits. The old telephone codes 99441–99443 are gone, replaced by these telemedicine-specific codes. If your templates haven’t been updated, now’s the time.
Modifiers and Place of Service
Modifiers are simpler than they used to be. Most telehealth codes now include the delivery mode, so Modifier 95 for video and Modifier 93 for audio-only are rarely required. Medicare may still ask for them in some scenarios, but most commercial payers don’t.
Place of Service codes matter for payment:
- POS 02: Patient is somewhere other than home (clinic, facility, etc.)
- POS 10: Patient is at home during the visit. Medicare reimburses at the non-facility rate, usually better financially
Other niche modifiers, like GT for Critical Access Hospitals or GQ for asynchronous federal projects, may come up in rare cases. It’s worth knowing when these apply so your claims don’t get held up.
Simple Best Practices
Billing doesn’t have to be a nightmare. A few habits can save you headaches and money:
- Check payer rules first. Medicaid and commercial payers have different code lists and documentation expectations, sometimes even by state.
- Write it all down. Mode of care, time spent, medical decision-making, and why telehealth was chosen; every detail matters.
- Document consent properly. Include date and method. Some payers won’t approve the visit without it.
- Use the right CPT codes. The 98000 series replaces old telephone codes, and your EHR should reflect this.
- Stay aware of temporary waivers. Some flexibilities end after September 2025. Know which rules still apply.
- Review before submitting. A missing detail can trigger claim denial, so a quick check saves stress later.
Doing these things consistently will make telemedicine billing changes much less daunting and help you get reimbursed on time.
Common Mistakes to Avoid
Even senior physicians commit minor yet expensive mistakes. The most frequent ones are the following:
- Applying old codes or modifiers.
- Missing out on mentioning whether the visit was audio or video.
- Missing patient consent
- Omitting documentation due to time or decision-making.
These errors are simple to avoid, provided that you have a habit of going through each note and claim prior to submission. Consider it a mini-audit whenever you are closing a telehealth visit.
Why Staying Updated Matters
Telehealth is here to stay. It’s gradually becoming a fixed part of the medical system. Regulations and payment conditions will continue to change, but practices that are up-to-date will reap the benefits. Having your records precise, applying the correct codes, and being familiar with the payer’s rules will maintain the claims at a steady flow and lessen the worries.
With alterations in telemedicine billing coming in 2025, it is really possible to do it correctly. Doing the right things now will result in an easier claims process, fewer rejections, and less time spent on obtaining payments.
Key Takeaways
- Make sure you document everything thoroughly: consent, place, mode of service, medical necessity, and notes.
- For new patients, utilize the 98000-series CPT codes, and for established patients, use the corresponding codes.
- While modifiers are easier, POS codes are still important.
- Confirm payer-specific rules and temporary waivers.
- Look over the notes before you submit the claims to avoid mistakes.
There is no need for telehealth billing to be very confusing. Just keep your codes updated, your documentation tight, and watch for any changes in the policy. When you do these things, billing becomes something you can handle, is in compliance, and is even predictable. By being up to date with the information, you are able to concentrate on what is most important, giving care, even if your patients are not in the same room.
