What Is a 95 Modifier and When Should You Use It?

The 95 modifier is important in medical billing as healthcare delivery evolves to include remote services. It identifies specific types of virtual healthcare encounters, ensuring proper classification and processing of claims. This modifier helps differentiate telehealth services from traditional in-person appointments for billing purposes.

Understanding the 95 Modifier

The 95 modifier is a medical billing code that indicates a healthcare service was provided via synchronous telemedicine, which means a live, real-time interactive audio and video telecommunications system. This modifier is appended to Current Procedural Terminology (CPT) codes, which are standard codes used to describe medical, surgical, and diagnostic services.

The American Medical Association (AMA) introduced the 95 modifier in 2017 to clearly distinguish telehealth visits from in-person appointments. By using this modifier, insurers can easily identify services delivered remotely and process claims based on the virtual nature of the interaction. This distinction is important for accurate tracking of telemedicine usage and for ensuring that providers receive appropriate reimbursement for services provided outside of a traditional office setting.

Applying the 95 Modifier

The 95 modifier is appropriately used for services delivered through real-time interactive audio and video technology, requiring both visual and auditory communication between the patient and the provider. Services conducted solely through audio-only phone calls or asynchronous methods, such as secure messaging or “store-and-forward,” generally do not qualify for the 95 modifier. However, some exceptions for audio-only services exist, particularly for behavioral health or in specific circumstances where audio-video technology is unavailable to the patient.

A wide range of services are eligible for the 95 modifier when delivered via synchronous telehealth. These commonly include evaluation and management (E/M) services, such as office visits for new and established patients, and behavioral health services like psychotherapy and psychiatric evaluations. Nutritional counseling and certain remote ophthalmologic services may also be billed with this modifier. Appendix P of the CPT manual lists codes that are generally suitable for reporting synchronous telemedicine services when the 95 modifier is applied.

Patient consent is a necessary component for telehealth services. Providers must obtain and document the patient’s consent for the telehealth encounter, confirming their agreement to receive care through telecommunication technology. Additionally, providers should verify payer-specific rules and state regulations, as these can influence the appropriate application of the 95 modifier and dictate any additional requirements for its use.

Reimbursement Considerations

The 95 modifier impacts how telehealth claims are processed for payment. When correctly used, it signals to the payer that a service was delivered remotely, which can affect the reimbursement amount and policies. While the modifier itself does not directly alter the reimbursement amount for the CPT or HCPCS code, it ensures the claim is processed as a telehealth service, making it eligible for payment under specific telehealth guidelines.

Reimbursement parity for telehealth services, meaning payment at the same rate as in-person services, can vary considerably. This parity is not universally guaranteed and depends on the specific payer (such as Medicare, Medicaid, or commercial insurers) and state regulations. Commercial payers frequently update their policies, and their requirements for the 95 modifier and associated reimbursement rates may differ.

Patients may also experience variations in cost-sharing, such as co-pays or deductibles, for telehealth services. While some policies may waive or reduce these costs for telehealth during certain times, the standard patient financial responsibilities generally apply unless otherwise specified by the payer or regulatory waivers. Providers should verify coverage and cost-sharing details with each patient’s insurance plan prior to service delivery to avoid unexpected financial burdens.

Essential Documentation

Documentation is essential when billing telehealth services with the 95 modifier to substantiate the service and ensure compliance. Providers must maintain comprehensive records that support the remote nature of the encounter. This includes documenting the patient’s informed consent for receiving telehealth services.

Detailed records should specify the technology used for the session, ensuring it meets the interactive audio and video requirements for synchronous telehealth. The documentation should also include the precise start and end times of the service, the location of both the patient and the provider during the encounter, and the medical necessity for delivering the service via telehealth rather than in-person. Clear and comprehensive medical records are crucial for audit purposes, helping to prevent claim denials and ensure accurate reimbursement.