Asynchronous Telehealth (Store-and-Forward Telemedicine): Formats, Examples, State Medicaid Rules, and CPT/HCPCS Coding

Asynchronous telehealth (also known as asynchronous telemedicine or store-and-forward telehealth, and defined under federal Medicare regulation 42 CFR § 410.78(a)(4)) is a clinical care delivery modality in which pre-recorded patient medical information—including structured adaptive clinical questionnaires, digital photographs, diagnostic radiological studies, ophthalmic fundus images, or recorded video clips—is transmitted electronically from an originating site or patient device to a distant-site practitioner who evaluates the data and formulates a diagnosis or treatment plan at a later time without simultaneous real-time interaction.

What Is Asynchronous Telehealth? (Definition & How Store-and-Forward Works)

In telehealth taxonomy, clinical encounters divide between synchronous telehealth (live, interactive two-way audio-video or audio-only visits where patient and clinician are present simultaneously, typically billed with CPT Modifier 95 or 93) and asynchronous telehealth (where data acquisition and clinician evaluation are decoupled in time).

When clinical exams, certification tests, or health informatics specifications ask “which statement accurately describes an asynchronous telehealth visit”, the defining criterion is temporal decoupling via store-and-forward transmission: clinical history, biometric readings, or diagnostic media are captured first, stored in a HIPAA-compliant encrypted queue, and forwarded to a licensed clinician who reviews the package asynchronously and returns a written assessment, prescription, or triage disposition within a defined service-level agreement (SLA, such as 2 to 24 hours).

What Is an Example of an Asynchronous Telehealth Format? (5 Core Clinical Modalities)

Across hospital systems, ambulatory networks, and decentralized clinical trials, asynchronous telehealth operates in five primary clinical formats:

Asynchronous Telehealth Format	Clinical Workflow & Data Payload Example	Governing Technical Standard	Primary CMS / CPT Billing Codes
1. Store-and-Forward Teledermatology & Wound Care	A patient or primary care medical assistant submits high-resolution macro and dermoscopic photographs of a skin lesion or chronic ulcer alongside lesion duration, pruritus/bleeding history, and medication list; a board-certified dermatologist reviews the case later and returns a diagnostic impression, topical/oral prescription, or biopsy order.	DICOM Visible Light (VL) / HL7 FHIR Media, DocumentReference, and QuestionnaireResponse	HCPCS G2010 (established patient image/video review) or CPT 99451 / 99452 (if provider-to-provider eConsult)
2. Diagnostic Teleradiology & Telepathology	An originating hospital CT/MRI scanner or whole-slide digital pathology scanner transmits lossless volumetric image files to a remote radiologist or pathologist for primary diagnostic interpretation.	DICOM (NEMA PS3 / ISO 12052), DICOMweb (WADO-RS, STOW-RS), HL7 v2 ORM/ORU	Modality-specific Radiology/Pathology CPT codes with Modifier 26 (Professional Component)
3. Teleophthalmology (Diabetic Retinopathy Screening)	A primary care clinic captures non-mydriatic digital retinal fundus photographs during a routine diabetes visit and forwards them to a remote ophthalmologist or optometrist (or FDA-cleared autonomous AI system) to grade diabetic macular edema and retinopathy.	DICOM Ophthalmic Photography (OP) IOD, HL7 FHIR DiagnosticReport	CPT 92227, 92228 (remote retinal imaging for disease detection/monitoring)
4. Online Digital Evaluation & Management (e-Visits / Structured Adaptive Intake)	An established patient initiates a clinical evaluation through a secure EHR patient portal or adaptive branching questionnaire (e.g., for acute sinusitis, urinary tract infection, conjunctivitis, or medication titration); the clinician reviews the chart and responds asynchronously.	HL7 FHIR Structured Data Capture (SDC) Questionnaire / Communication	CPT 99421 (5–10 min), 99422 (11–20 min), 99423 (21+ min cumulative over 7 days); HCPCS G2061–G2063 (non-physician qualified health professionals)
5. Interprofessional Specialist eConsults	A primary care provider packages a clinical question with labs, ECGs, and imaging via an eConsult platform (such as AristaMD, RubiconMD, or ConferMED) for asynchronous specialist chart review and care plan recommendations.	SMART on FHIR, HL7 C-CDA / FHIR ServiceRequest & DiagnosticReport	CPT 99452 (requesting clinician, 16–30 min) and CPT 99451 (consulting specialist, ≥ 5 min + written report)

CMS Medicare Reimbursement Rules for Asynchronous Telehealth

In federal telehealth reimbursement policy, healthcare compliance teams must distinguish between two separate statutory classifications created by the Social Security Act and CMS rulemaking:

1. Statutory “Medicare Telehealth Services” Under Section 1834(m) (42 CFR § 410.78): Under historic Section 1834(m)(1) of the Social Security Act, substituting an asynchronous store-and-forward transmission for a standard face-to-face Evaluation and Management (E/M) office visit code (such as CPT 99202–99215) using Modifier GQ is restricted in traditional Medicare to federal telemedicine demonstration programs conducted in Alaska and Hawaii.
2. Nationwide Medicare Coverage for Communication Technology-Based Services (CTBS): Beginning in the CY 2019 and CY 2020 Medicare Physician Fee Schedule Final Rules, CMS established that brief asynchronous virtual check-ins, remote image evaluations, online digital E/M services, and interprofessional eConsults are not restricted by Section 1834(m) geographic or originating-site limits and are reimbursable nationwide across all 50 states without Modifier GQ when billed under their dedicated CTBS codes:
   • HCPCS G2010 (Remote Evaluation of Recorded Video/Images): Covers asynchronous clinician review of patient-submitted photos or video clips for an established patient, including interpretation and follow-up communication within 24 business hours, provided the evaluation does not originate from a related E/M service within the previous 7 days or lead to an E/M visit within the next 24 hours (or soonest available appointment).
   • CPT 99421–99423 (Online Digital E/M Services / e-Visits): Covers patient-initiated asynchronous digital inquiry and management for an established patient over a 7-day cumulative period (99421: 5–10 minutes; 99422: 11–20 minutes; 99423: 21 or more minutes).

What States Allow Asynchronous Telehealth? (Medicaid & State Licensure Rules)

When digital health companies, multi-state medical groups, or clinical trial sponsors ask “what states allow asynchronous telehealth”, compliance hinges on two distinct state-level legal frameworks:

1. State Medicaid Store-and-Forward Reimbursement (32+ States)

According to the Center for Connected Health Policy (CCHP) national statutory and Medicaid policy tracking, more than 32 U.S. state Medicaid programs explicitly reimburse for asynchronous store-and-forward telehealth (including Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Georgia, Hawaii, Illinois, Iowa, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Montana, New Hampshire, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, Utah, Vermont, Virginia, Washington, and Wisconsin). Several state Medicaid programs reimburse store-and-forward across all clinical specialties, while others limit asynchronous Medicaid reimbursement to designated specialties such as teledermatology, teleophthalmology, teleradiology, telepathology, behavioral health, or teledentistry.

2. Establishing a Physician-Patient Relationship & Prescribing via Asynchronous Intake

For commercial and cash-pay asynchronous telehealth platforms, the critical legal boundary is whether state medical board rules allow a clinician to establish a valid practitioner-patient relationship and issue a non-controlled prescription for a new patient using an adaptive asynchronous clinical questionnaire (sometimes called a “static vs. dynamic/adaptive questionnaire” distinction):

• Permissive Asynchronous Relationship States: A growing majority of states permit a practitioner-patient relationship to be formed via asynchronous store-and-forward technology—provided the clinical intake collects a comprehensive medical history, photographs/diagnostic data where clinically necessary, and enables two-way asynchronous follow-up messaging meeting the in-person standard of care.
• Static Questionnaire Prohibitions: Virtually all state medical and pharmacy boards prohibit prescribing medications based solely on a “static internet questionnaire” (a fixed form without conditional clinical branching, identity verification, or clinician two-way clarification). Furthermore, under the federal Ryan Haight Online Pharmacy Consumer Protection Act (21 USC § 829(e)) and DEA telemedicine rules, controlled substances (Schedules II–V) cannot be prescribed purely via an asynchronous questionnaire.

Asynchronous Telehealth Software & HL7 FHIR Architecture

An enterprise asynchronous telehealth platform (such as Epic MyChart e-Visits, Fabric Health [formerly Zipnosis], Wheel, or specialty teledermatology/eConsult systems) implements four technical safeguards inside the EHR ecosystem:

• Conditional Clinical Branching & Red-Flag Escalation (HL7 FHIR SDC): Uses HL7 FHIR Structured Data Capture (SDC) Questionnaire definitions with CQL/FHIRPath branching logic. If a patient endorses an acute red-flag symptom (such as chest pain, focal neurologic deficit, or severe dyspnea during an acute respiratory intake), the software immediately halts the asynchronous flow and directs the patient to emergency care or a synchronous video visit.
• Structured EHR Chart Write-Back: Packages patient responses into a FHIR QuestionnaireResponse, attaches clinical images via Media or DocumentReference, creates a clinician worklist Task with SLA timers, and writes the signed diagnosis (ICD-10-CM) and e-prescription (NCPDP SCRIPT v2017071) back to the EHR.

Frequently Asked Questions

What is asynchronous telehealth?

Asynchronous telehealth (legally defined in federal regulation 42 CFR § 410.78(a)(4) as ‘store-and-forward technology’) is a modality of telemedicine in which a patient’s clinical data—such as structured symptom questionnaires, high-resolution clinical photographs, diagnostic imaging, pathology slides, or recorded video/audio clips—are captured, encrypted, and transmitted to a clinician at a distant site for evaluation, diagnosis, or treatment planning at a later time without real-time simultaneous interaction.

What is an example of an asynchronous telehealth format?

Common clinical examples of an asynchronous telehealth format include: (1) store-and-forward teledermatology (a patient or primary care clinic uploads macro/dermoscopic skin lesion photos and a structured symptom history for a dermatologist to evaluate later), (2) diagnostic teleradiology (transmitting DICOM CT or MRI scans from an emergency department PACS to a remote radiologist), (3) non-mydriatic retinal fundus photography for diabetic retinopathy screening, (4) patient portal online digital Evaluation and Management (e-Visits, CPT 99421–99423), and (5) physician-to-physician electronic consultations (eConsults, CPT 99451–99452).

Which statement accurately describes an asynchronous telehealth visit?

An asynchronous telehealth visit is accurately described as a store-and-forward clinical encounter in which the patient and the evaluating healthcare practitioner do not interact in real time; instead, clinical history, diagnostic images, or physiologic recordings are collected first and reviewed by the clinician asynchronously to render a documented clinical assessment, prescription, or care plan.

What states allow asynchronous telehealth?

All 50 U.S. states permit asynchronous communications (such as teleradiology, telepathology, and established-patient portal messaging) under state medical practice acts, and according to the Center for Connected Health Policy (CCHP), at least 32 state Medicaid programs explicitly reimburse for store-and-forward telehealth services (including Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Georgia, Hawaii, Illinois, Iowa, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Montana, New Hampshire, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, Utah, Vermont, Virginia, Washington, and Wisconsin). However, states differ on whether an initial physician-patient relationship and non-controlled prescription can be established purely via an adaptive asynchronous questionnaire without audio or video.

Sources

• Code of Federal Regulations — 42 CFR § 410.78 (Telehealth Services; Definition of Asynchronous Store-and-Forward Technology at § 410.78(a)(4)): law.cornell.edu/cfr/text/42/410.78
• Centers for Medicare & Medicaid Services (CMS) — Medicare Claims Processing Manual Chapter 12 & Communication Technology-Based Services (HCPCS G2010, CPT 99421–99423, CPT 99451–99452): cms.gov
• Center for Connected Health Policy (CCHP) — State Telehealth Laws and Reimbursement Policies: Store-and-Forward Policy Summary: cchpca.org/topic/store-and-forward
• HL7 International — FHIR R4 Workflow & Communication Resources (Task, Communication, QuestionnaireResponse): hl7.org/fhir/R4/workflow-communications.html