Telehealth Billing & Reimbursement: A Point of Attention for Healthcare Providers

Telehealth has fundamentally reshaped healthcare delivery, offering a convenient and effective way to connect with patients. As healthcare continues its digital evolution, services like Remote Patient Monitoring (RPM) are becoming critical for improving patient outcomes and managing costs. However, navigating the complex world of telehealth reimbursement can be a significant challenge for providers.

The rules governing reimbursement are a patchwork of federal, state, and private payer policies that are constantly changing. Understanding these nuances is essential for any practice looking to build a sustainable telehealth program. This guide will walk you through the key aspects of telehealth reimbursement, including RPM CPT codes, payer guidelines, and actionable steps you can take to prepare for upcoming policy changes and maximize your reimbursements.

The Rise of Remote Patient Monitoring (RPM)

Remote Patient Monitoring (RPM) is a key component of modern telehealth, allowing providers to manage acute and chronic conditions from a distance. By using digital medical devices to collect patient data, such as blood pressure or glucose levels, you can gain real-time insights into a patient’s health status.

The Centers for Medicare & Medicaid Services (CMS) recognizes the value of RPM and updates Current Procedural Terminology (CPT) billing codes each year to encourage its adoption. These codes provide a clear pathway for reimbursement, making RPM a financially viable option for many practices.

Understanding 2025 RPM CPT Codes

Staying current with RPM CPT codes is the first step toward successful reimbursement. By now, providers should be familiar with the following key codes for billing Medicare:

CPT Code 99453: This code covers the initial setup and patient education for using RPM devices. It is a one-time payment billed after the patient has been monitored for at least 16 days. The average national payment is approximately $19.73.
CPT Code 99454: This code covers the monthly costs associated with providing the RPM device and the collection and transmission of physiologic data. To bill for this code, the patient must use the device for at least 16 days within a 30-day period. The average national payment rate is around $43.03 per month.
CPT Code 99457: This code reimburses for the first 20 minutes of clinical staff time spent on interactive communication with the patient or caregiver regarding their RPM data each calendar month. This can include physicians, clinical staff, or other qualified healthcare professionals. The average national reimbursement for this code is $47.87.
CPT Code 99458: This is an add-on code for each additional 20 minutes of RPM service provided in a calendar month. The average national payment is $38.49 for each additional 20-minute increment.

It’s also important to note that Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) now use these same CPT codes for RPM services, moving away from the previously used G0511 code.

Essential Billing Requirements for RPM

To ensure your claims for RPM services are accepted, you must adhere to specific billing requirements set by CMS:

FDA-Approved Devices: The monitoring device must meet the FDA’s definition of a medical device.
Patient Consent: The patient must opt-in to the service before you order and provide the RPM device.
New Patient Evaluation: An evaluation is required for patients who are new to RPM services.
16-Day Usage Rule: To bill for codes 99453 and 99454, the patient must use the RPM device for at least 16 days out of a 30-day period.
HIPAA Compliance: All data collection and transmission must be secure and HIPAA-compliant.

Reimbursement for Telehealth: Payer Guidelines

Telehealth reimbursement isn’t a one-size-fits-all system. Policies vary significantly between Medicare, Medicaid, and private commercial insurers. Understanding the specific rules for each payer is crucial for financial success.

Medicare Telehealth Policies

Medicare’s telehealth policies have evolved considerably, particularly since the COVID-19 Public Health Emergency (PHE). While many pandemic-era flexibilities have been made permanent or extended, providers must stay informed about the latest rules.

As of 2025, CMS has permanently added several services to the Medicare Telehealth Services List, including group behavioral counseling for obesity and multiple-family group psychotherapy. CMS has also streamlined the process for adding new services to the list, signaling a long-term commitment to telehealth. For many services, Medicare reimburses telehealth visits at the same rate as in-person visits. After the patient meets their Part B deductible, they are responsible for 20% of the Medicare-approved amount.

However, some pre-pandemic restrictions are set to return. Without further Congressional action, key telehealth flexibilities expired on September 30, 2025. After this date, geographic and site restrictions reinstated for many services, meaning Medicare is generally covering telehealth for patients in designated rural areas and at approved originating sites (like a clinic or hospital), not their homes. Exceptions exist for mental and behavioral health services and monthly End-Stage Renal Disease (ESRD) visits.

Medicaid and Private Insurer Policies

Medicaid gives states broad flexibility in designing their telehealth policies. All 50 states and Washington, D.C., reimburse for some form of live-video telehealth, but coverage for other modalities like store-and-forward (asynchronous) technology and RPM varies. According to the Center for Connected Health Policy, 37 states currently reimburse for RPM under Medicaid. Because policies differ so much, providers must check their state’s specific Medicaid guidelines.

Private insurers have also expanded their telehealth coverage, but policies are not standardized. While 43 states have laws governing private payer telehealth reimbursement, these laws often focus on service parity (requiring coverage for services delivered via telehealth if they are covered in person) rather than payment parity (requiring equal reimbursement amounts). This means payers may still reimburse telehealth at a lower rate than in-person visits unless a state has an explicit payment parity law.

medicare telehealth policies and guidelines

How to Maximize Telehealth Reimbursement

With a complex and shifting policy landscape, providers need a clear strategy to navigate reimbursement and avoid financial risk. The following steps can help you prepare your practice and maximize revenue from telehealth services.

1. Prepare Patient, Provider, and Staff Communications

Clear communication is essential, especially with policy changes on the horizon. As the September 30, 2025 “telehealth cliff” approaches, you need to inform patients about how their access to telehealth may change.

Draft Patient Notices: Create clear, proactive communications explaining potential changes. For Medicare patients who may lose coverage for telehealth at home, consider including an Advance Beneficiary Notice of Non-coverage (ABN) to inform them of potential out-of-pocket costs.
Educate Your Staff: Ensure your billing and clinical staff understand the upcoming changes, including which provider types will remain eligible to offer telehealth services under Medicare after the deadline. For example, without new legislation, physical therapists, occupational therapists, and audiologists may no longer be eligible to provide telehealth services to Medicare beneficiaries.

2. Evaluate Your Financial Risk

The potential return of pre-pandemic restrictions requires a thorough financial risk assessment. Analyze your patient population and current telehealth usage to understand the potential impact on your revenue.

Assess Patient Impact: Identify how many of your Medicare patients are currently receiving telehealth services outside of an approved originating site (i.e., from their homes).
Develop a Contingency Plan: If Medicare no longer reimburses for these at-home visits, decide how your practice will respond. Will you absorb the cost, transition patients to in-person visits, or bill them directly?
Check Dual-Eligible Coverage: For patients eligible for both Medicare and Medicaid, check if your state’s Medicaid program covers the needed telehealth services. Ensure your clinicians are enrolled as Medicaid providers in that state.

3. Use the Medicare Telehealth Payment Eligibility Analyzer

To determine if a location qualifies as an eligible originating site for Medicare telehealth reimbursement, use the Medicare Telehealth Payment Eligibility Analyzer. This tool, provided by the Health Resources and Services Administration (HRSA), allows you to enter a street address and instantly check its eligibility. This is particularly useful for identifying accessible originating sites for your patients if at-home coverage is no longer an option.

4. Understand Telehealth Coding and Modifiers

Proper coding is fundamental to getting paid. For most telehealth services, you will use the same CPT codes as an equivalent in-person visit. However, you must also use specific modifiers and place of service (POS) codes to identify the service as telehealth.

Modifier 95: This modifier is used to indicate a synchronous telemedicine service rendered via a real-time interactive audio and video system. It should be appended to the relevant E/M codes (e.g., 99202-99215).
Place of Service (POS) Codes: Use code POS 10 when the patient is located in their home at the time of the telehealth visit, and POS 02 when the patient is at a location other than their home (e.g., a hospital or clinic).

Accurate use of these codes is essential for clean claims and timely reimbursement from both Medicare and private payers.

The Future of Telehealth Reimbursement

At Care Medicus, we recognize that the evolving landscape of telehealth reimbursement demands vigilance, adaptability, and strategic planning. Legislative changes and shifting payer policies—especially the uncertainty surrounding the “telehealth cliff”—require providers to stay ahead of regulatory developments while maintaining operational stability.

Now is the time to strengthen your telehealth program. Stay informed about policy updates, communicate expectations clearly with patients and staff, and proactively manage financial workflows to ensure sustainability. With thoughtful planning and expert support from Care Medicus, you can build a resilient telehealth model that not only meets regulatory requirements but also elevates patient access, convenience, and quality of care.

Together, we can help you turn regulatory complexity into opportunity and position your telehealth services for long-term success.

Post Views: 17

Care Medicus