Telemedicine has fundamentally changed how medical care is delivered, allowing many services once confined to the clinic to be provided remotely. This shift relies on a complex system of codes that designate the specific service and modality used for billing. Strict limitations exist on which codes can be accurately reported as telemedicine, primarily due to the physical nature of the service, the location of required equipment, or specific payer rules. Understanding these exclusions is necessary for proper billing compliance in remote healthcare.
Services That Require Physical Contact
Many medical services are inherently excluded from telemedicine codes because they necessitate direct, hands-on interaction between the provider and the patient. These procedures require tactile feedback, manipulation, or invasion of the body that cannot be replicated through audio-visual technology alone. For instance, codes for manual therapy techniques in physical therapy are non-reimbursable via telehealth, as the service description requires the application of skilled hands-on pressure.
Any code describing a surgical procedure, whether major or minor, is excluded from remote reporting because the intervention must occur in person. Codes for injections, such as joint or trigger point injections, or immunization administration, cannot be billed as telemedicine, as they involve the physical administration of a substance. Even visual assessments, such as the required hands-on examination of a vascular access site for End-Stage Renal Disease (ESRD) services, must be furnished face-to-face. These exclusions are based on the clinical requirement for physical presence to safely and effectively deliver the treatment.
Exclusions for Facility and Technical Components
Many diagnostic codes, particularly those for imaging services like radiology (e.g., CT scans or X-rays), are separated into two distinct billing parts: the Professional Component (PC) and the Technical Component (TC). The PC represents the physician’s service, which includes the interpretation of results and report generation, and is often eligible for remote billing using modifier 26. Conversely, the TC represents the cost of the physical site, equipment, supplies, and the technician’s time, which is billed by the facility where the procedure was performed.
Codes billed globally, meaning they include both the PC and the TC without a modifier, cannot be fully reported as a telemedicine service because the technical portion requires an in-person setting. Since the equipment and physical space represented by the TC are not at the distant site of the provider, the TC itself is non-billable by the professional as a remote service. This distinction ensures the provider is only reimbursed for the intellectual work of interpretation when the patient is at a separate location. Facility fees, which are institutional charges for the overhead of a hospital or clinic, are excluded from telehealth reimbursement entirely, as they represent costs tied to a physical location.
Limitations on Diagnostic and Procedural Codes
Diagnostic and procedural codes are excluded from telemedicine coverage if they require specialized infrastructure or the physical handling of biological material. For instance, codes related to the collection of specimens for laboratory testing necessitate an in-person visit for the sample to be physically obtained by trained personnel. Although the interpretation of the lab result might be a remote service, the initial collection code itself is an in-person activity that cannot be billed as telemedicine.
Complex neurological testing, such as the setup and monitoring phases of certain electroencephalogram (EEG) codes, often involves specialized equipment and in-person hook-up procedures performed at a facility. The remote provision of these services is incompatible with the codes’ descriptions, which assume the presence of specialized staff and apparatus. Codes for Durable Medical Equipment (DME), which involve the physical delivery and fitting of items like wheelchairs, oxygen tanks, or braces, are also excluded. This is because the service is tied to a tangible product and physical placement.
Regulatory and Payer-Specific Non-Covered Services
Beyond clinical necessity, many exclusions are driven by the specific rules and policies of individual payers, such as Medicare or private insurance companies. A service may be technically possible to perform remotely but still be listed as non-covered due to explicit regulatory limitations. For example, Medicare maintains a list of approved telehealth services, and any code not on that list is non-covered, regardless of its remote feasibility.
Coverage is dynamic and subject to policy changes, particularly following the expiration of temporary emergency flexibilities. Codes temporarily allowed during a public health emergency, such as certain audio-only services, may revert to a non-covered status or become subject to pre-pandemic restrictions. An example is the requirement for an in-person visit within a specified timeframe for mental health services. Providers must check payer-specific documentation, as a code’s coverage status can fluctuate based on legislative acts, state mandates, or the payer’s determination that a service lacks sufficient evidence for remote delivery.