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Since the COVID19 Pandemic started in 2020, the approach by payers related to telehealth has been fairly consistent and the CPT coding is the same CPT codes used for in person visits (e.g. 99212-99215). This is changing with 2025 since the Center for Medicare and Medicaid Services (CMS) provided an entirely new CPT coding approach. These new CPT codes selected vary depending on if the telehealth is voice only or voice and video. With the 2025 changes on the horizon, pediatric practices need to stay ahead of the curve to ensure proper reimbursement and compliance. At Physician Xpress, Inc., we are ready for these changes—the real question is, are the payers?
The 2025 Telehealth Coding Updates
The Centers for Medicare & Medicaid Services (CMS) and other stakeholders have made updates to telehealth coding guidelines that will impact pediatric practices. Some of the key changes include:
- Changes to Telehealth Service CPT Codes:
New codes have been introduced to accommodate the increasing scope of virtual care, particularly for differences between a voice only visit and a visit with voice and video. These codes now separate Video/Audio and Audio only into different CPT codes. Currently, Telehealth is reimbursed for sick visits via the E&M codes (e.g. 99212-99215).
- RVU values for CPT Codes – 2025 versus current:
Relevant Value Unit (RVU) is the measurement used by Medicare and the Healthcare system to determine the “value” of a CPT code based on the “Work”. The higher the value the higher the reimbursements. The new CPT codes (discussed below) currently have the ‘same’ RVU value for video/audio and lower value for the audio only when compared to CPT codes 99212-99215.
- Coverage Variability:
While CMS sets the baseline, private payers often lag in implementing coding changes, creating potential delays or denials in reimbursement.
Below is a summary of these new CPT codes related to telehealth visits in 2025..
If the practice conducts telehealth visits with video and audio (like a zoom call) then the four codes for established patients are:
98004 Telemedicine E/M Audio/ video(A/V) – 15 minutes or Straightforward MDM (Est patient)
98005 Telemedicine E/M Audio/ video(A/V) -30 minutes or Low MDM (Est patient)
98006 Telemedicine E/M Audio/ video(A/V) – 45 minutes or Moderate MDM (Est patient)
98007 Telemedicine E/M Audio/ video(A/V) 60 minutes or high MDM (Est patient)
Note that there are different telehealth codes for new patients (98000-98003)
If the practice conducts telehealth visits with audio only (similar to phone call) then the four codes for established patients are
98012 Telemedicine E/M Audio Only – 15 minutes or Straightforward MDM (Est patient)
98013 Telemedicine E/M Audio Only -30 minutes or Low MDM (Est patient)
98014 Telemedicine E/M Audio only – 45 minutes or Moderate MDM (Est patient)
98015 Telemedicine E/M Audio only – 60 minutes or high MDM (Est patient)
Note that there are different telehealth codes for new patients (98008-98011).
For additional information related to the CMS changes in telehealth coding for 2025, please refer to the federal register 2024-25382. ( https://public-inspection.federalregister.gov/2024-25382.pdf )
Navigating the Telehealth Billing Changes in 2025
At Physician Xpress, we have been monitoring these changes closely. Our pediatric-focused billing systems are fully updated to reflect the 2025 coding changes. Whether it’s applying the correct modifiers, navigating updated POS guidelines, or anticipating payer-specific policies, we ensure your practice is ready for the new coding environment.
We know from experience that payers do not always implement CMS updates in a timely or consistent manner. This can create challenges for pediatric practices when seeking reimbursement for telehealth visits. Some payers have a history of either claims processing systems that have denials of commonly accepted coding approaches or develop a coding requirement that is not common. Our team works proactively with payers to minimize denials, reduce delays, and maximize the revenue for your Pediatric practice. For the pediatric practices that currently implement telehealth visits, each account manager has contacted the practice to provide background on these changes.
What Pediatric Practices Should Do Now
Determine if the practice will implement telehealth visits in 2025: Identify if there are changes in the practice approach to telehealth in 2025.
Train Your Providers: Ensure your pediatricians and clinical staff are aware of new telehealth codes and any changes for 2025.
Understand reimbursement policies for Payers: Stay informed about each payer’s policies and implementation timelines for telehealth coding updates.
The Road Ahead: Be Proactive, Not Reactive
While Physician Xpress is fully prepared for the 2025 changes, we remain vigilant in ensuring payers are ready too. Our priority is to protect your revenue cycle and ensure that your practice is paid for every service delivered—whether in person or virtually.
