State Telehealth Billing Regulations: 2026 Guide

Telehealth billing in the United States is governed by a patchwork of federal rules, state statutes, Medicaid policies, and commercial payer requirements that vary on virtually every dimension: which providers can bill, which services qualify, what technology is required, whether audio-only is permitted, how reimbursement compares to in-person rates, and whether the patient's location matters. For multi-state health systems, telehealth companies, and billing teams, navigating this landscape requires granular, state-specific knowledge that changes frequently.

This guide provides a comprehensive overview of telehealth billing regulations across the 20 most populous states by healthcare provider count, covering parity laws, eligible providers, eligible services, originating site requirements, audio-only policies, interstate licensure, Medicaid policies, commercial payer requirements, place of service coding, modifier usage, and the CMS telehealth flexibilities that remain in effect — and those that may expire.

Federal Telehealth Billing Framework

Before examining state-specific rules, it is essential to understand the federal framework that sets the baseline for Medicare telehealth billing and influences state policies.

Medicare Telehealth Coverage

CMS maintains a list of Medicare-covered telehealth services, updated annually through the Physician Fee Schedule (PFS) rulemaking process. Key federal telehealth parameters as of 2026:

Geographic restrictions: Prior to the COVID-19 public health emergency (PHE), Medicare telehealth was limited to patients in rural Health Professional Shortage Areas (HPSAs) or counties outside Metropolitan Statistical Areas. The PHE waivers expanded telehealth to all geographic locations. The Consolidated Appropriations Act, 2023, and subsequent legislation extended many of these flexibilities, but some provisions require periodic reauthorization. As of 2026, the geographic restriction waiver has been extended, but providers should monitor Congressional action on further extensions.

Originating site: Pre-PHE, Medicare required the patient to be at an approved originating site (physician office, hospital, rural health clinic, etc.) — the patient's home was generally not an eligible originating site. PHE flexibilities and subsequent legislation allowed the home as an originating site. This flexibility has been extended but is subject to Congressional reauthorization.

Audio-only: Medicare coverage of audio-only (telephone) E/M services was authorized during the PHE and extended through legislation. Coverage is limited to specific services and requires that the patient have a prior established relationship with the provider. Audio-only services are billed with modifier 93 and are reimbursed at the same rate as audio-video telehealth for covered services.

Provider types: Medicare-eligible telehealth providers include physicians, nurse practitioners, physician assistants, nurse midwives, clinical nurse specialists, psychologists, clinical social workers, registered dietitians, and other qualified healthcare professionals as defined by CMS.

Place of Service Codes

POS 02 — Telehealth Provided Other than in Patient's Home: Used when the patient receives telehealth services at a facility or location other than their home.

POS 10 — Telehealth Provided in Patient's Home: Used when the patient receives telehealth services in their home. This code was introduced during the PHE and affects reimbursement — services billed with POS 10 are typically reimbursed at the non-facility (office) rate, while POS 02 may trigger the facility rate depending on where the provider is located.

Modifier 95: Indicates synchronous telehealth service rendered via real-time interactive audio and video telecommunications system. Used by Medicare and many commercial payers.

Modifier GT: Previously used to indicate interactive audio and video telecommunications. Modifier GT has largely been replaced by Modifier 95 for Medicare, but some commercial payers and state Medicaid programs still require modifier GT. Verify payer-specific requirements.

Modifier 93: Indicates audio-only telehealth service. Used when the service is provided via telephone without video.

Modifier FQ: Indicates the telehealth service was provided using audio-only when the patient is in their home and other requirements are met. Used for certain Medicare audio-only claims.

Facility Fee Differences

The POS code directly affects reimbursement. When POS 10 (patient at home) is used, CMS reimburses at the non-facility rate, which includes practice expense RVUs for overhead that the provider bears. When POS 02 is used and the patient is at an originating site that bills a facility fee (such as a hospital outpatient department), the provider is reimbursed at the facility rate (lower), and the originating site may bill a separate facility fee.

Practical implication: For telehealth encounters where the patient is at home, POS 10 generally results in higher provider reimbursement because the non-facility rate applies. Organizations should ensure their billing systems correctly assign POS codes based on patient location.

CMS Telehealth Flexibilities: Status and Expiration Risk

Several CMS telehealth flexibilities that were initially authorized during the COVID-19 PHE have been extended through legislation, but many require periodic reauthorization. As of early 2026, the following flexibilities are in effect but subject to expiration:

Flexibility	Current Status	Expiration Risk
Patient home as originating site	Extended through current legislation	Requires Congressional reauthorization
Geographic restriction waiver	Extended through current legislation	Requires Congressional reauthorization
Audio-only E/M coverage	Extended with limitations	Subject to annual PFS rulemaking
Telehealth for FQHCs and RHCs	Extended as distant site providers	Requires Congressional reauthorization
Initial patient visits via telehealth (no prior relationship)	Extended for behavioral health; limited for other services	Varies by service type
Telehealth prescribing of controlled substances (DEA)	DEA has issued rules requiring in-person evaluation for initial prescriptions after transition period	In transition; verify current DEA requirements

Action item for providers: Monitor CMS and Congressional action on telehealth legislation. Budget and operational planning should include contingency for potential expiration of flexibilities. Subscribe to CMS MLN Connects and relevant professional association updates for timely notification.

State-by-State Telehealth Billing Regulations

The following analysis covers the 20 states with the largest healthcare provider populations. For each state, the analysis addresses parity laws, eligible providers, eligible services, originating site requirements, audio-only policy, Medicaid telehealth coverage, and notable requirements.

California

Parity law: California requires payment parity for telehealth services — reimbursement must be at the same rate as equivalent in-person services (Cal. Bus. & Prof. Code 2290.5; Cal. Health & Safety Code 1374.14). The Telehealth Advancement Act of 2021 (AB 32) strengthened parity requirements and prohibited payers from requiring in-person contact as a condition of reimbursement.

Eligible providers: All healthcare providers licensed in California who are authorized to provide the service in-person may provide it via telehealth. No separate telehealth licensure is required.

Eligible services: Broadly defined. Any service that can be appropriately provided via telehealth is eligible. The provider determines clinical appropriateness.

Originating site: No originating site restrictions. The patient may be at home, at work, or at any location.

Audio-only: Permitted. AB 32 requires payers to cover audio-only telehealth services when audio-video is not available to the patient, and requires payment parity for audio-only services.

Medicaid (Medi-Cal): Medi-Cal covers telehealth services with payment parity. Both audio-video and audio-only modalities are covered. Managed care plans must cover telehealth at in-person rates.

Notable: California's telehealth framework is among the most provider-friendly in the nation. Cross-state licensure considerations apply — California does not participate in many interstate compacts, and out-of-state providers generally must hold a California license to treat patients located in California.

Texas

Parity law: Texas requires commercial insurers to cover telehealth services (Tex. Ins. Code 1455.004) and prohibits plans from excluding a service solely because it is provided via telehealth. Texas does not mandate full payment parity — payers may negotiate telehealth rates that differ from in-person rates.

Eligible providers: Physicians, advanced practice nurses, physician assistants, psychologists, licensed clinical social workers, dietitians, and other licensed healthcare providers. Texas law distinguishes between "telemedicine" (physician services) and "telehealth" (services by other providers).

Eligible services: Services must be clinically appropriate for telehealth delivery. Payers may not impose geographic restrictions on patient location.

Originating site: No originating site restrictions for commercial insurance. The patient may be located anywhere in Texas.

Audio-only: Permitted for certain services. Texas Medicaid allows audio-only for behavioral health and certain other services. Commercial payer coverage of audio-only varies.

Medicaid: Texas Medicaid covers telehealth services and has progressively expanded coverage post-PHE. Both synchronous (real-time) and store-and-forward modalities are covered for certain specialties.

Notable: Texas does not participate in the Interstate Medical Licensure Compact. Out-of-state providers must hold a Texas license or a telehealth-specific registration. The Texas Medical Board has specific rules governing the standard of care for telemedicine.

New York

Parity law: New York requires payment parity for telehealth services provided by in-network providers (N.Y. Ins. Law 3217-h; N.Y. Pub. Health Law 2999-cc). Payers must reimburse telehealth services at the same rate as in-person services.

Eligible providers: Physicians, nurse practitioners, licensed clinical social workers, psychologists, dentists, midwives, and other licensed professionals authorized by New York law. New York enacted expanded telehealth provider eligibility through the "Telehealth Modernization Act."

Eligible services: Broadly defined. Mental health services, primary care, specialist consultations, and other clinical services are covered. Payers may not impose restrictions on covered services solely based on delivery modality.

Originating site: No originating site restrictions. Patient home is an eligible site.

Audio-only: Permitted. New York law requires coverage of audio-only telehealth for mental health services and has extended audio-only coverage to other service categories. Providers must document why audio-video was not used.

Medicaid: New York Medicaid covers telehealth services with payment parity. Managed care plans are required to provide the same telehealth coverage. Audio-only is covered for behavioral health and select primary care services.

Notable: New York requires informed consent for telehealth services, which must be documented in the medical record. New York does not participate in the Interstate Medical Licensure Compact.

Florida

Parity law: Florida requires coverage of telehealth services by commercial insurers (Fla. Stat. 456.47) but does not mandate payment parity. Payers may reimburse telehealth services at rates different from in-person services.

Eligible providers: Licensed healthcare professionals authorized to provide the service in-person. Florida uses the term "telehealth provider" and requires providers to register with the Florida Board of Medicine or relevant licensing board if practicing from out of state.

Eligible services: Services that the provider determines are clinically appropriate for telehealth delivery. Florida does not maintain a restrictive list of eligible services.

Originating site: No originating site restrictions. The patient may be at home or any location.

Audio-only: Permitted. Florida statute includes audio-only (telephone) in its definition of telehealth. Coverage and reimbursement for audio-only vary by payer.

Medicaid: Florida Medicaid covers telehealth services. The Agency for Health Care Administration (AHCA) has expanded Medicaid telehealth coverage and allows managed care plans to cover audio-only services.

Notable: Florida's out-of-state provider registration process allows providers licensed in other states to treat Florida patients via telehealth without obtaining a full Florida license, subject to registration requirements and limitations.

Pennsylvania

Parity law: Pennsylvania requires commercial insurers to cover telehealth services and mandates payment parity (40 Pa. Stat. 764.3). Reimbursement must be at the same rate as the equivalent in-person service.

Eligible providers: Licensed physicians, CRNPs, physician assistants, psychologists, licensed clinical social workers, and other licensed healthcare providers.

Eligible services: Services that can be appropriately delivered via telehealth. No restrictive service list.

Originating site: No originating site restrictions. Patient home is eligible.

Audio-only: Permitted for certain services, particularly behavioral health. Coverage varies by payer for other service categories.

Medicaid: Pennsylvania Medicaid covers telehealth and has maintained expanded coverage post-PHE. Managed care organizations are required to cover telehealth services. Audio-only coverage has been extended for behavioral health and certain primary care services.

Notable: Pennsylvania participates in the Interstate Medical Licensure Compact, allowing physicians licensed through the Compact to practice telehealth across member states.

Illinois

Parity law: Illinois requires payment parity for telehealth services (215 ILCS 5/356z.22). Commercial insurers must reimburse telehealth at the same rate as in-person services. The parity requirement is strong and broadly applied.

Eligible providers: All licensed healthcare professionals authorized by their practice act to provide the service.

Eligible services: All services that can be appropriately delivered via telehealth. Illinois has one of the broadest definitions of telehealth-eligible services.

Originating site: No originating site restrictions. Patient may be at any location.

Audio-only: Permitted. Illinois law specifically includes audio-only telehealth in its parity requirements. Payers must cover and reimburse audio-only services at parity when audio-video is not available.

Medicaid: Illinois Medicaid covers telehealth with payment parity. The Department of Healthcare and Family Services has maintained broad telehealth coverage post-PHE.

Notable: Illinois requires informed consent for telehealth, which may be verbal but must be documented. Illinois participates in the Interstate Medical Licensure Compact.

Ohio

Parity law: Ohio requires commercial insurers to cover telehealth services (Ohio Rev. Code 3902.30) but allows payers to negotiate reimbursement rates that may differ from in-person rates. Ohio does not mandate full payment parity.

Eligible providers: Licensed physicians, APRNs, physician assistants, psychologists, licensed counselors, and other licensed providers.

Eligible services: Services appropriate for telehealth delivery as determined by the provider.

Originating site: No originating site restrictions for commercial insurance.

Audio-only: Permitted for certain services. Ohio Medicaid covers audio-only for behavioral health. Commercial coverage varies.

Medicaid: Ohio Medicaid covers telehealth services and has maintained expanded coverage. Managed care plans are required to cover telehealth.

Notable: Ohio participates in the Interstate Medical Licensure Compact. Ohio has specific informed consent requirements for telehealth encounters.

Georgia

Parity law: Georgia requires coverage of telemedicine services by commercial insurers (Ga. Code 33-24-56.4). Georgia mandates payment parity — reimbursement for telehealth must be at the same rate as the equivalent in-person service. This parity requirement was strengthened by SB 789 and subsequent legislation.

Eligible providers: Licensed physicians, APRNs, physician assistants, and other licensed healthcare providers.

Eligible services: Services appropriate for telehealth delivery. Georgia does not maintain a restrictive list.

Originating site: No originating site restrictions. The patient may be at home.

Audio-only: Permitted. Georgia law includes telephone-only encounters in its definition of telemedicine for certain service categories.

Medicaid: Georgia Medicaid covers telehealth services. Coverage has been expanded and maintained post-PHE.

Notable: Georgia participates in the Interstate Medical Licensure Compact. Georgia requires that providers establish a provider-patient relationship before providing prescriptions via telehealth, with exceptions for specific circumstances.

North Carolina

Parity law: North Carolina requires commercial insurers to cover telehealth services and mandates payment parity (N.C. Gen. Stat. 58-3-247). The parity law was enacted in 2021 and strengthened in subsequent sessions.

Eligible providers: Licensed physicians, nurse practitioners, physician assistants, psychologists, licensed clinical social workers, and other licensed healthcare providers.

Eligible services: Broadly defined. Services appropriate for telehealth as determined by the provider.

Originating site: No originating site restrictions. Patient home is eligible.

Audio-only: Permitted for behavioral health and primary care services. Audio-only coverage requirements were codified in the parity legislation.

Medicaid: North Carolina Medicaid covers telehealth services with payment parity. The transition to Medicaid managed care has maintained telehealth coverage requirements.

Notable: North Carolina participates in the Interstate Medical Licensure Compact and the ASWB Mobility initiative for social work licensure.

Michigan

Parity law: Michigan requires commercial insurers to cover telehealth services (Mich. Comp. Laws 500.3476) and mandates payment parity. Payers must reimburse telehealth at the same rate as in-person services.

Eligible providers: Licensed healthcare providers authorized by their professional licensing act.

Eligible services: Broadly defined. Services appropriate for telehealth delivery.

Originating site: No originating site restrictions.

Audio-only: Permitted. Michigan law includes audio-only telehealth in its coverage requirements.

Medicaid: Michigan Medicaid covers telehealth services including audio-only. Managed care plans must cover telehealth.

Notable: Michigan participates in the Interstate Medical Licensure Compact.

New Jersey

Parity law: New Jersey requires coverage and payment parity for telehealth and telemedicine services (N.J. Stat. 45:1-62). The parity requirement is among the strongest in the nation.

Eligible providers: Licensed healthcare providers, including physicians, APNs, physician assistants, psychologists, social workers, and other licensed professionals.

Eligible services: All services that can be appropriately provided via telehealth.

Originating site: No originating site restrictions.

Audio-only: Permitted. New Jersey law specifically includes audio-only telehealth in parity requirements.

Medicaid: New Jersey Medicaid covers telehealth services with payment parity including audio-only.

Notable: New Jersey participates in the Interstate Medical Licensure Compact. The state requires informed consent for telehealth, which must be documented.

Virginia

Parity law: Virginia requires commercial insurers to cover telehealth services and mandates payment parity (Va. Code 38.2-3418.16). Reimbursement must be at the same rate as in-person services.

Eligible providers: Licensed healthcare providers authorized to provide the service in-person.

Eligible services: Services appropriate for telehealth delivery.

Originating site: No originating site restrictions.

Audio-only: Permitted for mental health services and certain primary care services. Audio-only parity requirements are specified in statute.

Medicaid: Virginia Medicaid covers telehealth with payment parity. Audio-only is covered for behavioral health and primary care.

Notable: Virginia participates in the Interstate Medical Licensure Compact.

Washington

Parity law: Washington requires payment parity for telehealth services (Wash. Rev. Code 48.43.735). Commercial insurers must reimburse telehealth at the same rate as in-person services. The parity law is comprehensive and applies to all covered services.

Eligible providers: Licensed healthcare providers. Washington has broad telehealth provider eligibility.

Eligible services: All services that can be appropriately delivered via telehealth.

Originating site: No originating site restrictions.

Audio-only: Permitted. Washington specifically mandates coverage and payment parity for audio-only telehealth services.

Medicaid (Apple Health): Washington Medicaid covers telehealth with payment parity, including audio-only. The Health Care Authority has maintained broad telehealth coverage.

Notable: Washington participates in the Interstate Medical Licensure Compact. The Washington My Health My Data Act creates additional health data privacy requirements relevant to telehealth platforms.

Massachusetts

Parity law: Massachusetts mandates telehealth coverage and payment parity (Mass. Gen. Laws ch. 175, 108P). Insurers must cover telehealth at the same rate as in-person services. Massachusetts was among the first states to enact comprehensive telehealth parity.

Eligible providers: Licensed healthcare providers authorized by their licensing board.

Eligible services: All services appropriate for telehealth delivery.

Originating site: No originating site restrictions.

Audio-only: Permitted. Massachusetts specifically requires coverage and parity for audio-only services.

Medicaid (MassHealth): MassHealth covers telehealth services with payment parity, including audio-only. Coverage is broad and has been maintained post-PHE.

Notable: Massachusetts does not participate in the Interstate Medical Licensure Compact. Out-of-state providers must hold a Massachusetts license to treat patients in the state.

Arizona

Parity law: Arizona requires commercial insurers to cover telehealth services (Ariz. Rev. Stat. 20-841.09) and mandates payment parity.

Eligible providers: Licensed healthcare providers authorized to provide the service in-person.

Eligible services: Services appropriate for telehealth delivery as determined by the provider.

Originating site: No originating site restrictions.

Audio-only: Permitted for certain services. Arizona law includes telephone consultations in its telehealth definition.

Medicaid (AHCCCS): Arizona Medicaid covers telehealth services through its managed care plans. Audio-only coverage is available for behavioral health and certain primary care services.

Notable: Arizona participates in the Interstate Medical Licensure Compact.

Maryland

Parity law: Maryland requires telehealth coverage and payment parity (Md. Code, Ins. 15-139). Payers must reimburse at the same rate as in-person services.

Eligible providers: Licensed physicians, nurse practitioners, nurse midwives, licensed clinical social workers, psychologists, and other licensed providers.

Eligible services: All clinically appropriate services.

Originating site: No originating site restrictions.

Audio-only: Permitted. Maryland law specifically includes audio-only in telehealth coverage and parity requirements.

Medicaid: Maryland Medicaid covers telehealth services with payment parity, including audio-only.

Notable: Maryland participates in the Interstate Medical Licensure Compact. Maryland has specific telehealth informed consent requirements.

Minnesota

Parity law: Minnesota requires telehealth coverage and payment parity (Minn. Stat. 62A.672). The parity requirement applies to commercial insurance and is comprehensive.

Eligible providers: Licensed healthcare providers authorized by their licensing board.

Eligible services: All services that can be appropriately provided via telehealth.

Originating site: No originating site restrictions.

Audio-only: Permitted. Minnesota mandates coverage and parity for audio-only services.

Medicaid (Medical Assistance): Minnesota Medicaid covers telehealth with payment parity, including audio-only. The Department of Human Services has maintained expanded coverage.

Notable: Minnesota participates in the Interstate Medical Licensure Compact.

Colorado

Parity law: Colorado requires telehealth coverage and payment parity (Colo. Rev. Stat. 10-16-123). Payers must cover telehealth at the same rate as in-person services.

Eligible providers: Licensed healthcare providers.

Eligible services: All clinically appropriate services.

Originating site: No originating site restrictions.

Audio-only: Permitted. Colorado mandates coverage and payment parity for audio-only telehealth.

Medicaid: Colorado Medicaid covers telehealth with payment parity, including audio-only.

Notable: Colorado participates in the Interstate Medical Licensure Compact. The Colorado AI Act (SB 21-169) imposes additional requirements on AI systems used in telehealth if they are classified as high-risk.

Indiana

Parity law: Indiana requires commercial insurers to cover telehealth services (Ind. Code 27-8-34) and mandates payment parity.

Eligible providers: Licensed physicians, APRNs, physician assistants, and other licensed providers.

Eligible services: Services appropriate for telehealth delivery.

Originating site: No originating site restrictions.

Audio-only: Permitted for certain services, particularly behavioral health. Coverage for audio-only varies by payer.

Medicaid: Indiana Medicaid covers telehealth services. Managed care plans must cover telehealth.

Notable: Indiana participates in the Interstate Medical Licensure Compact.

Tennessee

Parity law: Tennessee requires coverage of telehealth services by commercial insurers (Tenn. Code 56-7-1002) and mandates payment parity.

Eligible providers: Licensed healthcare providers authorized to provide the service.

Eligible services: Services appropriate for telehealth delivery.

Originating site: No originating site restrictions.

Audio-only: Permitted for certain services. Tennessee Medicaid covers audio-only for behavioral health.

Medicaid (TennCare): TennCare covers telehealth services and has maintained expanded coverage post-PHE. Managed care organizations must cover telehealth.

Notable: Tennessee participates in the Interstate Medical Licensure Compact.

State Telehealth Policy Comparison Table

State	Payment Parity	Audio-Only Covered	Audio-Only Parity	IMLC Member	Patient Home Eligible	Medicaid Telehealth
California	Yes	Yes	Yes	No	Yes	Yes, with parity
Texas	No	Limited	No	No	Yes	Yes
New York	Yes	Yes	Limited	No	Yes	Yes, with parity
Florida	No	Yes	No	No	Yes	Yes
Pennsylvania	Yes	Yes	Limited	Yes	Yes	Yes
Illinois	Yes	Yes	Yes	Yes	Yes	Yes, with parity
Ohio	No	Limited	No	Yes	Yes	Yes
Georgia	Yes	Yes	Limited	Yes	Yes	Yes
North Carolina	Yes	Yes	Limited	Yes	Yes	Yes, with parity
Michigan	Yes	Yes	Yes	Yes	Yes	Yes
New Jersey	Yes	Yes	Yes	Yes	Yes	Yes, with parity
Virginia	Yes	Yes	Limited	Yes	Yes	Yes, with parity
Washington	Yes	Yes	Yes	Yes	Yes	Yes, with parity
Massachusetts	Yes	Yes	Yes	No	Yes	Yes, with parity
Arizona	Yes	Limited	Limited	Yes	Yes	Yes
Maryland	Yes	Yes	Yes	Yes	Yes	Yes, with parity
Minnesota	Yes	Yes	Yes	Yes	Yes	Yes, with parity
Colorado	Yes	Yes	Yes	Yes	Yes	Yes, with parity
Indiana	Yes	Limited	Limited	Yes	Yes	Yes
Tennessee	Yes	Limited	Limited	Yes	Yes	Yes

Interstate Practice and Licensure Compacts

Interstate Medical Licensure Compact (IMLC)

The IMLC provides an expedited pathway for physicians to obtain medical licenses in multiple states. As of 2026, 42 states, the District of Columbia, and Guam are IMLC members. The Compact does not create a national license — physicians must still obtain individual state licenses, but the IMLC streamlines the application process.

Implications for telehealth: Physicians licensed through the IMLC can more easily provide telehealth services to patients in other Compact states. However, the physician must hold a license in the state where the patient is located at the time of the telehealth encounter, not just the state where the physician is located.

Psychology Interjurisdictional Compact (PSYPACT)

PSYPACT allows psychologists and psychology associates to practice telepsychology and conduct temporary in-person practice across PSYPACT member states. Over 40 states have enacted PSYPACT legislation.

Nurse Licensure Compact (NLC)

The NLC allows registered nurses and licensed practical nurses to practice in their home state and other Compact states. Over 40 states participate in the NLC. Nurse practitioners are covered under a separate compact (the APRN Compact), which has fewer member states.

Social Work Licensure Compact

The social work licensure compact facilitates interstate practice for licensed social workers, including telehealth services. The compact is being adopted by states progressively.

Counseling Compact

The Counseling Compact provides a framework for licensed professional counselors to practice across state lines, including via telehealth. States are in various stages of adoption.

Important limitation of all compacts: Compacts facilitate licensure but do not override state scope-of-practice laws, telehealth regulations, or payer-specific requirements. A provider licensed through a compact in another state must still comply with that state's telehealth regulations and payer requirements.

Billing Best Practices for Multi-State Telehealth

1. Bill According to the Patient's Location

The state where the patient is physically located at the time of the telehealth encounter determines which state's laws, licensing requirements, and billing rules apply. The provider's location is generally irrelevant for regulatory purposes (though it may affect the provider's tax obligations).

2. Verify Payer-Specific Telehealth Requirements

State parity laws set minimums, but individual payers may have specific requirements for telehealth billing — including prior authorization, modifier requirements, eligible service limitations, and documentation standards. Verify payer-specific telehealth policies before billing.

3. Document Modality and Consent

For every telehealth encounter, document:

• The modality used (synchronous audio-video, audio-only, asynchronous/store-and-forward)
• That the technology was adequate for clinical assessment
• Patient consent for telehealth (if required by the state)
• The patient's physical location at the time of the encounter

4. Use Correct POS and Modifier Codes

Assign POS 10 when the patient is at home and POS 02 when the patient is at a facility. Apply modifier 95 for synchronous audio-video services and modifier 93 for audio-only services. Verify payer-specific modifier requirements, as some payers have unique modifier requirements.

5. Monitor Regulatory Changes

Telehealth regulations change frequently. State legislatures amend telehealth laws annually, CMS updates Medicare telehealth policy through the annual PFS rulemaking, and individual payers update their telehealth policies. Establish a process for monitoring and incorporating regulatory changes into billing practices.

6. Maintain State-Specific Billing Protocols

For organizations providing telehealth across multiple states, maintain state-specific billing protocols that document the requirements for each state. These protocols should be reviewed and updated at least annually.

7. Credential and License Proactively

Ensure all telehealth providers hold active, unrestricted licenses in every state where they provide telehealth services. Use interstate compacts where available to streamline licensure. Monitor license renewal dates and compact membership status.

8. Train Billing Staff on Telehealth Requirements

Billing staff must understand the differences between in-person and telehealth billing, including POS code selection, modifier application, payer-specific requirements, and documentation standards. Training should be updated when state or payer requirements change.

Common Telehealth Billing Errors

Incorrect POS code: Using POS 11 (office) instead of POS 10 or POS 02 for telehealth encounters. This results in incorrect reimbursement and creates audit vulnerability.

Missing modifiers: Failing to apply modifier 95 (audio-video) or modifier 93 (audio-only). Some payers will deny claims without the appropriate telehealth modifier.

Audio-only billing where not covered: Billing audio-only services to payers or in states that do not cover audio-only telehealth. This results in denials and potential compliance issues.

Billing telehealth services not on covered list: Some payers maintain specific lists of telehealth-eligible services. Billing for services not on the covered list results in denials.

Out-of-state practice without licensure: Providing telehealth to a patient in a state where the provider is not licensed. This is both a billing error (the claim may be denied) and a legal violation (unauthorized practice of medicine).

Facility fee billing errors: Billing originating site facility fees when the patient is at home. Originating site facility fees are only appropriate when the patient is at an eligible originating site facility.

Missing documentation of patient location: Failing to document the patient's physical location at the time of the telehealth encounter. This is necessary for determining which state's laws apply and for correct POS code assignment.

The Future of Telehealth Billing Regulation

Telehealth billing regulation is moving in a clear direction: toward permanence and uniformity, but slowly and unevenly. Most states have enacted or strengthened payment parity laws, and the trend toward removing originating site restrictions and allowing patient home as an eligible site appears irreversible. Audio-only coverage is expanding but remains inconsistent.

The federal picture is less certain. CMS telehealth flexibilities that were initially authorized as emergency measures are being extended through periodic legislation, but they have not been made permanent. The potential expiration of geographic waivers and originating site flexibilities creates planning uncertainty for organizations that have built telehealth programs on the assumption that these flexibilities will continue.

Interstate licensure compacts are expanding membership and streamlining cross-state telehealth practice, but significant gaps remain — particularly for states with large provider and patient populations (California and New York do not participate in the IMLC).

For healthcare organizations, the practical path forward is to build billing systems and compliance programs that can accommodate state-specific variation while positioning for increasing uniformity. Invest in billing technology and staff training that supports multi-state telehealth compliance. Monitor regulatory developments at both the state and federal level. And document telehealth encounters with the specificity needed to demonstrate compliance with whichever state's rules apply to each individual patient encounter.