What is the Evaluation and Management (EM) code for telemedicine services for patients with [INSURANCE_PROVIDER] insurance in [STATE]?

Telemedicine EM Coding: Insurance and State-Specific Guidance

For telemedicine evaluation and management (EM) services, use the standard office visit CPT codes (99201-99205 for new patients, 99211-99215 for established patients) with modifier 95 appended to indicate the service was delivered via real-time interactive audio-video technology. 1

Core Coding Requirements

Standard EM Codes with Telemedicine Modifier

• Use CPT codes 99201-99205 for new patient office visits delivered via telemedicine 1
• Use CPT codes 99211-99215 for established patient office visits delivered via telemedicine 1
• Append modifier 95 to any eligible CPT code to designate telemedicine delivery 1
• The modifier 95 requires real-time interactive audio and video telecommunications—asynchronous (store-and-forward) technology does NOT qualify except in Alaska and Hawaii 1

Technology Requirements for Reimbursement

• Interactive audio AND video communication is mandatory for modifier 95 use 1
• The patient must be present and participating in real-time during the encounter 1
• Audio-only telephone visits do NOT qualify for standard EM codes with modifier 95 1

Insurance-Specific Considerations

Medicare Coverage

• Medicare expanded telemedicine coverage significantly during COVID-19, eliminating geographic restrictions and allowing the patient's home as an originating site 1
• Medicare pays the distant site provider according to the Medicare Physician Fee Schedule 1
• The originating site (where the patient is located) can bill separately using HCPCS code Q3014 for a facility fee 1
• Post-pandemic, many Medicare waivers may expire, so verify current coverage status regularly 1

Medicaid Coverage

• All 50 states and the District of Columbia provide some form of Medicaid reimbursement for telemedicine as of 2021 1
• Most states mirrored Medicare's COVID-19 expansions for Medicaid programs 1
• Reimbursement criteria vary significantly by state, including which services are covered, payment rates, and geographic restrictions 1
• Some states cover store-and-forward and remote monitoring in addition to live video 1

Commercial Insurance

• 42 states plus the District of Columbia require commercial insurers to cover telehealth services, though not necessarily at parity with in-person care 1
• Coverage mandates apply only to plans originating in that state—out-of-state plans and ERISA plans may not be subject to state mandates 1
• Verify coverage with each individual commercial carrier as policies vary widely 1

State-Specific Requirements

Critical State-Level Variations

• Telemedicine payment policies are determined at the state level, making it essential to understand your specific state's regulations 1
• State licensure requirements typically mandate that providers be licensed in the state where the patient is located during the telemedicine encounter 1
• 29 states participate in the Interstate Medical Licensure Compact, which facilitates (but does not guarantee) multi-state licensure 1

Recommended Resource

• The Center for Connected Health Policy website provides state-by-state telemedicine policy information and should be consulted for your specific state 1

Common Pitfalls to Avoid

Documentation and Compliance

• Never use modifier 95 with audio-only encounters—this will result in claim denials 1
• Ensure your technology platform meets HIPAA requirements, as enforcement relaxations during COVID-19 are ending 2
• Document that both audio and video were used throughout the encounter 1
• Verify the patient's physical location is in a state where you hold an active license 1

Billing Errors

• Do not assume COVID-19 waivers remain in effect—many temporary expansions have expired or will expire 1
• Check whether your patient's insurance plan originates in your state, as out-of-state plans may not be subject to state telemedicine mandates 1
• For Medicare patients, verify the originating site is eligible for the facility fee before billing Q3014 1

Additional Eligible Telemedicine Services

Beyond standard office visits, other services eligible for telemedicine delivery with modifier 95 include: 1

• Consultations (CPT 99241-99245)
• Hospital follow-up care (99231-99233, limited to once every 3 days) 1
• Psychiatric services (90791,90792,90832-90838,90845-90847,90863) 1
• Prolonged services (99354-99355) 1

The landscape of telemedicine reimbursement remains fluid post-pandemic, requiring providers to regularly verify current policies with payers and state regulatory bodies before delivering services. 1