Disaster Telehealth Rules: [Self-Audit Checklist] (42 CFR § 410.78(a))

Telehealth plays a critical role in disaster preparedness for small healthcare clinics by enabling continuity of care when in-person services are disrupted. Medicare coverage for telehealth services is governed by 42 CFR § 410.78, which defines what qualifies as telehealth, establishes technology standards, identifies eligible patient locations, and outlines documentation requirements. This article explains how small clinics can align disaster-response telehealth workflows with Medicare rules to reduce claim denials, repayment risk, and audit exposure.

Natural disasters, public health emergencies, and regional infrastructure disruptions can severely limit a clinic’s ability to provide in-person care. For small clinics with limited staffing and resources, telehealth offers a practical way to maintain access to care during these events. However, telehealth services furnished during disasters must still comply with Medicare’s permanent regulatory framework.

Medicare telehealth coverage is not governed by emergency discretion alone. Instead, payment rules are established in 42 CFR § 410.78, which applies regardless of whether services are furnished during routine operations or emergency conditions. Small clinics that fail to align disaster telehealth protocols with this regulation risk denied claims and repayment obligations once normal oversight resumes.

Telehealth Definitions and Baseline Requirements Under 42 CFR § 410.78

What qualifies as Medicare telehealth

Under 42 CFR § 410.78(a), Medicare telehealth services are services furnished using an interactive telecommunications system that permits two-way, real-time audio and video communication between the patient and the distant-site practitioner.

This definition applies across all clinical settings, including disaster response scenarios. Telehealth encounters must meet this baseline definition unless a specific regulatory exception applies.

Audio-video as the standard

Medicare telehealth generally requires audio-video communication. Clinics should assume audio-video is required unless they can clearly document why an audio-only exception applies.

Audio-only telehealth (limited exception)

Audio-only telehealth is permitted only when all of the following conditions are met:

• The distant-site practitioner is technically capable of furnishing audio-video telehealth

• The patient is not capable of, or does not consent to, the use of video technology

• Required billing modifiers are appended to the claim

Required modifiers for audio-only services

• CPT modifier 93

• Medicare modifier FQ (for Rural Health Clinics and Federally Qualified Health Centers)

Audio-only use during disasters must be documented with the same rigor as during routine operations.

Originating site requirements

An originating site is the location of the Medicare beneficiary at the time telehealth services are furnished. Medicare allows telehealth only when the patient is located at an originating site recognized in 42 CFR § 410.78(b)(3), unless a specific exception applies.

Approved originating sites include, among others:

• Physician or practitioner offices

• Hospitals

• Rural health clinics

• Federally qualified health centers

• Skilled nursing facilities

• Community mental health centers

• Certain home-based settings for defined services

Patient home is not universally permitted

The patient’s home qualifies as an originating site only in defined circumstances, such as:

• Home dialysis monthly ESRD-related clinical assessments

• Treatment of substance use disorder (or co-occurring mental health disorder)

• Mental health telehealth services furnished to the patient in the home, subject to additional timing requirements

During disasters, clinics must still confirm and document that the patient’s location qualifies under the regulation.

Disaster response often involves behavioral health services. Small clinics must apply the correct in-person visit timing rules when furnishing mental health telehealth to a beneficiary in their home.

Services through December 31, 2024

For mental health telehealth furnished in the patient’s home during the period beginning after the end of the emergency period and ending December 31, 2024, Medicare payment requires:

• An in-person visit within 6 months prior to the initial telehealth service

• An in-person visit at least once within 12 months of each subsequent telehealth service

An exception applies if the practitioner and patient determine that in-person care poses greater risk or burden and document that determination.

Services on or after January 1, 2025

For services furnished on or after January 1, 2025, payment requires:

• An in-person visit within 6 months prior to the initial telehealth service

• An in-person visit within 6 months of any subsequent telehealth service

Small clinics must ensure disaster protocols reflect the correct timing standard based on the service date.

Only practitioner types listed in 42 CFR § 410.78(b)(2) may furnish and bill for Medicare telehealth services. These include physicians, nurse practitioners, physician assistants, clinical psychologists, clinical social workers, marriage and family therapists, mental health counselors, and certain other specified practitioners.

Disaster staffing plans should confirm that telehealth services are furnished only by eligible practitioner types.

Step 1: Identify telehealth-eligible services

Confirm that the service is on the Medicare Telehealth Services List for the applicable period.

Step 2: Verify practitioner eligibility

Confirm the rendering clinician qualifies as an eligible distant-site practitioner.

Step 3: Confirm and document patient location

Document where the patient is physically located at the time of the encounter and confirm it qualifies as an originating site.

Step 4: Document technology modality

Record whether audio-video or audio-only technology was used.

Step 5: Apply audio-only conditions and modifiers

If audio-only was used, document why video was not used and apply required modifiers.

Step 6: Track mental health in-person timing

For mental health services in the home, track in-person visit timing based on service date.

Step 7: Perform post-disaster claim review

After the event, review telehealth claims for documentation completeness and billing accuracy.

Simplified Self-Audit Checklist for Disaster Telehealth

• Service appears on the Medicare Telehealth Services List

• Rendering clinician is an eligible distant-site practitioner

• Patient location is documented and qualifies as an originating site

• Modality is documented (audio-video or audio-only)

• Audio-only visits include required justification and modifiers

• Mental health in-person visit timing is met for the applicable period

• Documentation supports all billed elements

CMS (Medicare payment enforcement)

CMS and Medicare contractors enforce compliance with 42 CFR § 410.78. Claims that do not meet coverage or documentation requirements may be denied or recouped after review.

OCR (HIPAA enforcement only)

The Office for Civil Rights enforces HIPAA privacy and security requirements for telehealth platforms and data handling. OCR does not enforce Medicare telehealth payment rules but may investigate privacy or security violations arising from telehealth use during disasters.

Common Pitfalls During Disaster Telehealth

• Relying on audio-only calls without documenting regulatory conditions

• Failing to document patient location during emergency operations

• Applying outdated mental health in-person timing rules

• Omitting required modifiers due to rushed billing

• Continuing temporary emergency workflows after normal operations resume

Small clinics should integrate telehealth compliance into disaster preparedness planning. Assigning responsibility for telehealth compliance, maintaining accessible documentation templates, and performing routine claim sampling help ensure emergency responses remain compliant with Medicare rules.

Telehealth can be a powerful disaster-response tool for small clinics, but Medicare coverage depends on compliance with 42 CFR § 410.78. Clinics must verify service eligibility, patient location, technology modality, practitioner eligibility, and documentation requirements, even during emergencies.

To further strengthen your compliance posture, consider using a compliance regulatory tool. These platforms help track and manage requirements, provide ongoing risk assessments, and keep you audit-ready by identifying vulnerabilities before they become liabilities, demonstrating a proactive approach to regulators, payers, and patients alike.

• 42 CFR 410.78 ,  Medicare telehealth services

• CMS Telehealth Services List

• HHS Telehealth Resources

• OCR HIPAA Guidance for Telehealth

• Federal Register ,  CMS Telehealth Rule Updates