Place-of-service and modifier requirements have diverged between payers again, so a single telehealth billing rule no longer works across a panel. Each payer now has to be handled on its own terms, and the licensure question sits underneath all of it.
During the emergency period, telehealth billing converged. Rules relaxed in similar directions and one internal approach mostly worked. That convergence has ended, and practices carrying the old habit are generating denials.
Where payers now differ
- Place of service. Which code to use, and whether it should reflect the patient's location or the provider's.
- Modifiers. Which one, whether one is required at all, and whether audio-only needs a different one.
- Audio-only coverage. Some payers cover it, some require video, and some cover it for defined services only.
- Originating site. Whether the patient may be at home, and whether geography matters.
- Service eligibility. Which services may be delivered remotely at all.
The licensure layer
Separately from billing, the provider generally must be licensed where the patient is located. A patient traveling out of state turns a routine visit into a licensure question, and the resulting claim can be denied for reasons that have nothing to do with the telehealth rules.
What a workable process looks like
A per-payer reference recording place of service, modifier, and audio-only position. Patient location captured at the visit rather than assumed. And denial monitoring specifically on telehealth claims, because when a payer changes its position the first signal is a cluster of denials rather than an announcement.
The rules are still moving. Building the per-payer reference is what makes the next change survivable.
Build the matrix once
One table: payer, accepted place-of-service code, required modifier, audio-only stance, and any originating-site condition. It takes an afternoon to assemble from your contracts and payer bulletins, and it prevents the denial pattern where every telehealth claim to one payer rejects for a month before anyone notices the rule changed.
Give it an owner and a review date tied to contract renewals. A matrix nobody maintains is worse than none, because staff trust it.
The denials to watch for
Telehealth denials cluster: wrong place of service, missing modifier, service not covered by that modality, and patient location outside the clinician’s licensure. The first two are corrected claims; the second two are not, and resubmitting them wastes the filing window.
Group these by reason rather than counting them, because each group has a different fix and only two of the four are recoverable.
Document the patient’s location every time
Your authority to treat and your ability to bill both turn on where the patient physically was during the encounter. A note that records "telehealth visit" without a location leaves you unable to answer the question a payer audit or a licensing board will eventually ask.
Capture it as a structured field rather than free text. It takes a second at check-in and it is the single piece of evidence that makes a telehealth chart defensible.
Behavioral health diverged from the rest
Telehealth rules for behavioral health have followed a different path from general medical telehealth, with different permanence and different conditions. A practice applying one rule across both service lines will be wrong on one of them.
Where you deliver both, maintain the distinction explicitly in the payer matrix rather than assuming a single telehealth policy.
Audio-only is the sharpest divide
Some payers cover audio-only encounters for defined services with specific codes, some do not cover them at all, and some require documentation that video was attempted and failed.
That last requirement is easy to miss and impossible to satisfy retroactively. If a payer requires it, the note has to say so at the time.
Watch for policy expiry dates
Several payer telehealth policies carry explicit end dates and are extended, or not, on their own schedule. A policy that has been renewed three times can lapse on the fourth without any announcement reaching you.
Diary the expiry dates alongside the matrix, because the denial pattern that follows a lapse is otherwise inexplicable.
Common questions
- What place of service code do I use for telehealth?
- It depends on the payer and on where the patient was located. Payers diverged after the flexibilities lapsed, so a single code applied across the panel will generate denials.
- Which modifier is required for telehealth claims?
- That also varies by payer now. Build a per-payer matrix rather than a single house rule, and review it when contracts renew.
- Do I need a license in the patient’s state for telehealth?
- Generally yes. Practice is deemed to occur where the patient is located, so the patient’s state licenses the encounter regardless of where the clinician sits.
- Are audio-only telehealth visits billable?
- For some payers and some services, with specific codes or modifiers. It is one of the areas payers diverge on most, so confirm per payer rather than assuming.
- How do I keep telehealth rules straight across payers?
- A one-page matrix of payer, place of service, modifier and audio-only stance, owned by a named person and reviewed at contract renewal.
Denials Piling Up?
We handle the revenue cycle end to end — coding by certified coders, claim submission, denial management and appeals, and A/R follow-up, with six reported numbers every month.