AI Telehealth Billing: CMS 2024-2026 Flexibilities, CPT Telehealth Codes, and Ryan Haight Act Compliance

Published February 25, 2026Reading time ~11 min

Telehealth billing has been in a state of regulatory flux since the COVID-19 public health emergency (PHE) triggered a massive expansion of covered services and relaxed requirements. CMS extended many PHE telehealth flexibilities through December 31, 2024, and Congress extended further extensions into 2025 and 2026 through appropriations legislation. The complexity of telehealth billing — multiple place-of-service codes, audio-only vs. video visit distinctions, originating site requirements, state licensure rules, and the Ryan Haight Act's prescribing restrictions — creates significant compliance risk for healthcare organizations that don't have automated billing controls. AI telehealth billing platforms can validate service requirements, assign correct CPT and place-of-service codes, flag Ryan Haight Act compliance issues, and ensure correct Medicare and Medicaid claim submission.

$29B

Estimated annual U.S. telehealth market size by 2025 (McKinsey Global Institute)

McKinsey Global Institute estimated that the U.S. telehealth market would reach $29 billion annually by 2025, compared to under $3 billion before the COVID-19 pandemic. CMS reported approximately 28 million telehealth visits under Medicare in 2022, down from the PHE peak but dramatically higher than pre-pandemic levels. The permanence of expanded telehealth coverage — particularly for behavioral health — creates an ongoing need for compliant AI telehealth billing systems that correctly apply the constantly evolving CMS telehealth coverage rules.

CMS Medicare Telehealth Services — Annual Physician Fee Schedule Updates

CMS PFS Final Rule — 2026 Telehealth Extensions and Behavioral Health Permanency

Authority: Social Security Act §1834(m); 42 CFR §410.78
2024-2026: COVID-19 telehealth flexibilities extended through 2026 via appropriations
POS Codes: POS 02 (telehealth, patient not home); POS 10 (telehealth, patient home)
GT Modifier: GT modifier for live synchronous audio/video telehealth (Medicare)
Audio-Only: CPT G2252/G2251 for audio-only visits (behavioral health: permanent)
Originating Site: Originating site fee (Q3014) payable for rural/HPSA originating sites
Ryan Haight: Ryan Haight Online Pharmacy Consumer Protection Act — DEA prescribing rules
State Licensure: Provider must be licensed in state where patient is located

CMS Telehealth Coverage Framework

Medicare telehealth services are authorized under Social Security Act §1834(m) and implemented at 42 CFR §410.78. The coverage framework involves multiple components:

Eligible services: CMS publishes an annual list of Medicare telehealth services — services not on the list cannot be billed as telehealth. AI billing must validate that each service is on the current CMS telehealth services list before applying telehealth billing rules.
Eligible providers: Physicians, NPPs (NPs, PAs, CNSs, CRNAs), RNs (specific services), and other practitioners specifically included in CMS telehealth rules may provide telehealth services. AI billing must verify provider type eligibility.
Geographic and originating site requirements: Pre-PHE, Medicare telehealth was restricted to patients in rural or healthcare professional shortage areas (HPSAs) at approved originating sites. PHE flexibilities suspended these requirements; extensions through 2026 maintain flexibility but may not be permanent.
Technology requirements: Real-time, interactive audio-visual communication is required for most telehealth services. Audio-only visits qualify only for specific service types (behavioral health, in patient's home) and require appropriate CPT codes.

Behavioral Health Telehealth Permanency: The Consolidated Appropriations Act of 2023 made several behavioral health telehealth flexibilities permanent, including: telehealth for mental health services without geographic restrictions, audio-only mental health services in patient's home, and federally qualified health center (FQHC) and rural health clinic (RHC) coverage of behavioral health telehealth. AI billing systems should apply permanent behavioral health rules separately from temporary extension rules.

CPT Telehealth Codes and Place-of-Service

Correct CPT code and place-of-service (POS) code assignment is critical for telehealth billing:

POS 02: Telehealth provided other than in patient's home — used when the patient receives telehealth at a location other than their home (e.g., originating site facility)
POS 10: Telehealth provided in patient's home — created by CMS to separately track telehealth provided directly to patients in their homes. This POS code affects Medicare payment under the physician fee schedule
GT modifier: Required on Medicare telehealth claims to indicate the service was provided via interactive audio-video technology
95 modifier: Used by many commercial payers for telehealth synchronous services
Audio-only codes: CPT G2252 (5-10 min audio-only assessment) and G2251 (complex audio-only assessment) for behavioral health audio-only visits; other audio-only rules vary by payer

Ryan Haight Act and Telehealth Prescribing

In-person requirement: The Ryan Haight Act generally requires one in-person examination before prescribing controlled substances via telemedicine
PHE exception: During the COVID-19 PHE, DEA waived the in-person requirement — this waiver has been extended multiple times but is not permanent
DEA Special Registrations: DEA finalized rules for Special Registrations allowing telemedicine prescribing of Schedule III-V substances without in-person visit (2024) — Schedule II (opioids, stimulants) remain more restricted
State-level prescribing rules: State medical boards have separate telehealth prescribing rules that may be more restrictive than federal DEA rules

Compliance Checklist

Annual CMS Telehealth Services List Validation
Each January, CMS publishes an updated Medicare Telehealth Services List in the Physician Fee Schedule Final Rule. AI billing systems must be updated with the new list before January 1 billing begins. Services not on the list cannot be billed as telehealth to Medicare regardless of how they were delivered. Track additions (new telehealth codes) and removals (services no longer covered as telehealth) annually. Many COVID-19 temporary telehealth additions have been given Category 1 or Category 2 permanent status — track classification for each service.

POS Code Accuracy Automation
Configure AI billing to assign the correct telehealth POS code based on patient location at time of service: POS 02 for telehealth at a facility originating site; POS 10 for telehealth provided directly to patient in their home. The POS code determination should be captured in the telehealth intake workflow — patients should confirm their location at the start of each telehealth visit. Incorrect POS codes cause claim rejections and may trigger audit scrutiny.

Ryan Haight Act Controlled Substance Prescribing Checks
Implement AI prescribing compliance checks for controlled substance prescribing via telehealth. Before allowing a provider to prescribe a Schedule II-IV controlled substance on a telehealth encounter: verify whether an in-person visit has occurred with this patient (satisfying Ryan Haight requirement), check current DEA extension status and Special Registration rules, verify state telehealth prescribing laws for the state where the patient is located. Document the compliance rationale for each controlled substance telehealth prescription.

State Licensure Verification for Telehealth Providers
Telehealth providers must be licensed in the state where the patient is physically located at the time of service — not where the provider is located. AI scheduling for telehealth should verify provider licensure in the patient's state before booking. Implement real-time state licensure verification using state medical board APIs or a credentialing database that tracks each provider's active state licenses. Serving patients in states where the provider is not licensed creates professional board, malpractice, and billing compliance risk.

Audio-Only Visit Documentation Requirements
Audio-only telehealth visits have specific documentation requirements to support billing. For Medicare audio-only mental health visits (G2252/G2251): document that audio-video was not available or accessible to the patient, confirm the patient's consent to audio-only service, and document the clinical rationale for the service. Commercial payer rules for audio-only vary — AI billing should apply payer-specific audio-only rules rather than assuming uniform coverage.

Originating Site Fee Billing Management
When patients receive Medicare telehealth at an eligible rural or HPSA originating site facility (rather than at home), the originating site may bill Medicare for the originating site facility fee using HCPCS code Q3014 (~$28). AI billing should identify originating site visits, verify the site is in a qualifying rural area or HPSA, and generate Q3014 claims for originating site facilities. Originating site fee eligibility is based on the patient's location — post-PHE, the location rules will revert to pre-PHE originating site requirements for non-behavioral health services.

Frequently Asked Questions

What CMS telehealth flexibilities remain in effect in 2026?

Congress has extended many COVID-19 telehealth flexibilities through appropriations legislation. As of 2026: (1) geographic restrictions for most Medicare telehealth services remain suspended; (2) patients may receive telehealth in their homes (POS 10); (3) audio-only telehealth for mental health services is permanent under the Consolidated Appropriations Act of 2023; (4) FQHCs and RHCs may provide telehealth as distant sites (permanent for behavioral health); (5) certain COVID-19 telehealth temporary additions have been given permanent Category 1 or 2 status on the CMS telehealth services list. Always verify current status on cms.gov as rules change annually.

What place-of-service codes are used for telehealth billing?

CMS uses two telehealth-specific POS codes: POS 02 (telehealth, patient not in their home) for telehealth visits where the patient is at an approved originating site facility; POS 10 (telehealth, patient in their home) for telehealth services delivered directly to patients at home. The distinction matters for payment: POS 10 claims reimburse at the non-facility rate (higher payment) because the physician's office overhead is lower when the patient is at home. Many commercial payers also use POS 02 and 10, but verify each payer's specific telehealth billing instructions.

What is the Ryan Haight Act and how does it affect telehealth?

The Ryan Haight Online Pharmacy Consumer Protection Act (21 U.S.C. §829(e)) requires an in-person medical evaluation before prescribing controlled substances via telemedicine — with limited exceptions. During the COVID-19 PHE, DEA waived this requirement. The waiver has been extended multiple times. In 2024, DEA finalized Special Registration rules allowing registered telemedicine practitioners to prescribe Schedule III-V controlled substances without in-person visits under specific conditions. Schedule II substances (opioids, stimulants) face more restrictive rules. Check current DEA and state board guidance before prescribing controlled substances via telehealth.

Do HIPAA rules apply to telehealth platforms?

Yes. Telehealth platforms that transmit or store PHI (patient communications, video visit recordings, clinical notes) are subject to HIPAA. Key requirements: (1) telehealth vendors are business associates requiring HIPAA BAAs; (2) video transmission must be encrypted (TLS in transit); (3) telehealth recordings may not be stored without appropriate PHI protections; (4) patients must be authenticated before telehealth visits; (5) access controls must prevent unauthorized viewing of telehealth sessions. During the COVID-19 PHE, OCR exercised enforcement discretion for certain consumer-grade video platforms — this enforcement discretion has ended and standard HIPAA requirements now apply to all telehealth technology.

How are audio-only telehealth visits billed differently from video visits?

Audio-only telehealth (telephone-only visits) are billed using different CPT codes than synchronous audio-video telehealth. For Medicare: audio-only E&M visits use telephone E&M codes (99441-99443) or audio-only behavioral health codes (G2252/G2251). Audio-video visits use the standard E&M CPT codes (99202-99215) with POS 02 or 10 and the GT modifier. Commercial payer audio-only rules vary widely — some payers cover audio-only at the same rate as video; others cover only audio-video or pay reduced rates for audio-only. AI billing must apply payer-specific audio-only rules to avoid systematic undercoding or billing for uncovered services.

AI Telehealth Billing That Keeps Up With CMS Rule Changes

Claire's telehealth billing AI validates services against the current CMS telehealth services list, assigns correct POS 02/10 codes and GT modifiers, checks Ryan Haight Act compliance for controlled substance prescribing, verifies state licensure, and applies payer-specific audio-only rules — all updated annually with CMS PFS changes.

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