💻 How to Code for Telehealth Visits

Telehealth (or telemedicine) involves providing healthcare services remotely using technology such as video conferencing, phone calls, or patient portals.

Correct coding ensures accurate reimbursement, regulatory compliance, and quality data reporting.

1. Identify the Type of Telehealth Service

Telehealth services are coded based on how the interaction occurs:

Type of Service Description Examples

Synchronous (Real-Time) Live video or audio communication between provider and patient Video visits, phone consultations

Asynchronous (Store-and-Forward) Transmission of recorded health data (e.g., images, lab results) for later review Dermatology photo reviews, radiology reads

Remote Patient Monitoring (RPM) Collection of health data via devices Blood pressure or glucose monitoring

Virtual Check-ins & E-Visits Brief digital communications between visits Portal messages, phone check-ins

2. Common Telehealth CPT and HCPCS Codes

A. Evaluation and Management (E/M) – Video or Audio Visits

Use standard office/outpatient E/M codes for real-time video visits:

Code Description

99202–99215 Office or outpatient visit (new or established patients) — used for telehealth when criteria are met

G0406–G0408 / G0425–G0427 Telehealth consults for inpatient, SNF, or outpatient settings (Medicare-specific)

Tip: For audio-only (telephone) visits, use:

99441–99443 → Physician/qualified provider telephone evaluation

98966–98968 → Non-physician (e.g., nurse, therapist) telephone assessment

B. Virtual Check-Ins

Brief communications to determine if an office visit is needed.

Code Description

G2012 Brief communication (5–10 min) with an established patient via phone or video

G2010 Remote evaluation of recorded video/images submitted by patient

Important: Patient consent and documentation of time and service type are required.

C. Online Digital E/M (E-Visits)

For patient-initiated messages through secure platforms (like MyChart).

Code Provider Type Description

99421–99423 Physicians/QHPs Cumulative time over 7 days (5–10 min, 11–20 min, 21+ min)

98970–98972 Non-physician providers Similar time-based structure

D. Remote Patient Monitoring (RPM)

For ongoing digital health data collection.

Code Description

99453 Initial setup and patient education on monitoring device

99454 Device supply and data transmission (per 30 days)

99457–99458 Monitoring and management (20+ minutes per month)

3. Use Correct Modifiers and Place of Service (POS)

Modifiers

Modifier Meaning When to Use

95 Synchronous telehealth via real-time audio/video For E/M and other live telehealth visits

GT Via interactive audio and video (used by some payers) Some Medicaid/commercial plans still require it

GQ Asynchronous (store-and-forward) When provider reviews transmitted data later

25 Separate E/M on same day as procedure When both telehealth and another service occur

Place of Service (POS)

POS Code Meaning

02 Telehealth provided other than patient’s home

10 Telehealth provided in patient’s home

Note: Always verify payer-specific POS requirements.

4. Documentation Requirements

To support telehealth billing, documentation must include:

Patient consent for telehealth

Date and time of service

Mode of communication (video, audio, asynchronous)

Location of provider and patient

Clinical details (assessment, diagnosis, treatment plan)

Duration of encounter (for time-based codes)

5. Common Telehealth Coding Errors

🚫 Using in-person E/M codes without modifier 95 or correct POS

🚫 Missing patient consent documentation

🚫 Billing audio-only services as video visits

🚫 Incorrect time documentation for time-based codes

🚫 Failing to check payer-specific telehealth policies

6. Best Practices for Accurate Telehealth Coding

✅ Verify payer coverage (Medicare, Medicaid, commercial) — rules differ.

✅ Ensure the visit meets medical necessity and documentation standards.

✅ Use secure, HIPAA-compliant technology.

✅ Keep up with annual telehealth policy updates from CMS and payers.

In Summary

Coding for telehealth visits requires careful attention to visit type, communication method, appropriate codes/modifiers, and complete documentation.

When done correctly, telehealth coding supports both compliance and proper reimbursement while improving patient access to care.

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November 04, 2025

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