What's Happening?
CPT code 99443, which covers telephone evaluation and management services for established patients lasting 21-30 minutes, remains active in the American Medical Association (AMA) code set for 2025-2026. However, its reimbursement landscape is complex
and varies significantly by payer. While the AMA introduced new 98000-series audio-only telehealth codes in 2023 as an expanded framework, both series now coexist. Medicare fee-for-service coverage for 99443 reverted to pre-Public Health Emergency (PHE) policies after the COVID-119 PHE ended, limiting reimbursement in many scenarios. Commercial payers and state Medicaid programs have diverse policies, with some migrating to the newer 98000-series and others continuing to reimburse 99443. Practices must verify each payer's current telehealth fee schedule and policy before billing to avoid denials. Common reasons for denials include undocumented call time, billing for new patients (as 99443 is for established patients only), or if the call leads to an in-person visit within 24 hours.
Why It's Important?
The evolving status of CPT code 99443 and the introduction of new audio-only telehealth codes have significant implications for healthcare providers' revenue cycles and patient access to care in the U.S. The lack of uniform payer policies creates administrative burdens for practices, requiring meticulous verification of coverage rules for each insurer and state Medicaid program. This complexity can lead to claim denials, delayed reimbursements, and potential loss of revenue if not managed effectively. For patients, inconsistent coverage for audio-only telehealth services could impact their ability to receive timely medical advice and follow-up care, especially for those who face barriers to video-based telehealth or in-person visits. The situation underscores the ongoing challenge of integrating telehealth into standard medical practice and the need for clearer, more standardized billing guidelines to support its widespread adoption and ensure equitable access.
What's Next?
Healthcare providers will need to implement robust internal processes to manage the complexities of billing for audio-only telehealth services in 2025-2026. This includes regularly checking payer-specific telehealth policies, training billing staff on the distinctions between CPT 99443 and the newer 98000-series codes, and ensuring thorough documentation of call duration and patient eligibility. Practices may also consider utilizing claims management software that validates code-payer combinations and flags potential documentation gaps before submission. The ongoing divergence in coverage between Medicare, commercial payers, and state Medicaid programs suggests that advocacy efforts may continue to push for greater standardization and clarity in telehealth reimbursement policies to reduce administrative overhead and improve patient access to care.
Beyond the Headlines
The intricate billing landscape for CPT code 99443 reflects a broader tension in the U.S. healthcare system: balancing innovation in care delivery with established reimbursement structures. While telehealth offers undeniable benefits in terms of accessibility and convenience, the financial mechanisms supporting it are still catching up. The varying acceptance of audio-only codes highlights a debate about the value and scope of different telehealth modalities. This situation could inadvertently create a two-tiered system where access to certain telehealth services depends on a patient's insurance provider or geographic location. Ultimately, the long-term success of telehealth integration will require not just technological advancements but also comprehensive policy reforms that ensure consistent, fair, and transparent reimbursement for all medically necessary virtual care services, fostering a more equitable and efficient healthcare ecosystem.
