What Is Modifier 93 and How Is It Used?

Medical coding modifiers provide additional details about a medical procedure or service without altering the core code. These two-character additions offer specific context to payers, influencing reimbursement and helping prevent claim denials. Telemedicine has transformed healthcare delivery, offering patients increased convenience and access to care from their homes.

Telemedicine has grown substantially, with virtual consultations becoming more accessible. Modifier 93 is instrumental in accurately reporting these remote services. It identifies a specific type of telemedicine encounter, ensuring proper communication between providers and payers about the service delivered.

Understanding Modifier 93

Modifier 93 designates a synchronous telemedicine service, involving real-time interaction between a healthcare professional and a patient at a distant site. This interaction occurs through live, interactive audio and video telecommunication systems. Synchronous telemedicine is a real-time exchange sufficient to meet the requirements of an in-person service.

While commonly associated with audio-visual visits, Modifier 93 can also be used for services via audio-only telecommunication systems. This is relevant when a patient lacks video capacity, does not consent to video use, or for specific behavioral health services.

This modifier is appended to Current Procedural Terminology (CPT) codes, which represent specific medical services. Adding “93” to a CPT code conveys that the service was delivered remotely through synchronous means. This indicates to payers that the patient’s location is not necessarily a traditional medical facility, differentiating it from in-person services.

Conditions for Use

For a healthcare service to qualify for Modifier 93, several specific criteria must be met, ensuring the integrity and appropriateness of the remote interaction. The service must involve real-time, interactive communication between the patient and the healthcare provider. This typically means a live audio and visual connection, though audio-only is permissible in certain circumstances, such as when a patient lacks video technology or does not consent to its use. The interaction must be equivalent in nature and amount to what would occur during a traditional in-person visit.

Medical necessity remains a fundamental condition for any healthcare service, including those delivered via telemedicine. The service must be medically appropriate and necessary for the patient’s condition, just as it would be for an in-person consultation. Providers are also generally required to be licensed in the state where the patient is physically located at the time of the service, not just where the provider is practicing. Many states have adopted interstate licensure compacts or specific telehealth registrations to facilitate cross-state practice, but providers should always verify the specific requirements.

The technology employed for telemedicine services must be secure and compliant with the Health Insurance Portability and Accountability Act (HIPAA). This means using platforms that ensure the confidentiality, integrity, and availability of protected health information (PHI) through measures like encryption and user authentication. Providers should ensure that any third-party vendors involved in the telemedicine platform have signed Business Associate Agreements (BAAs) to maintain HIPAA compliance.

Obtaining informed patient consent is also a prerequisite for telemedicine services. This consent should clearly explain the nature of telemedicine, its potential benefits and risks, and privacy considerations. Patients should understand the technology being used and their rights, including the ability to terminate the consultation at any time without affecting future care. Documentation of this consent is an important part of the patient’s medical record.

Claim Submission and Record Keeping

When submitting claims for services rendered via synchronous telemedicine using Modifier 93, healthcare providers append the modifier directly to the appropriate CPT code. For example, if a CPT code for an office visit is 99213, it would be billed as 99213 + 93. This modifier provides the payer with essential information about how the service was delivered.

On standard claim forms, such as the CMS-1500, modifiers are typically placed in specific fields alongside the CPT codes to which they apply. In electronic health record (EHR) systems, the process is integrated, allowing the modifier to be added electronically. The accurate placement of this two-character code is necessary for proper claim processing and reimbursement.

Thorough and accurate medical record documentation is necessary to support the use of Modifier 93. Documentation should clearly indicate that the service was provided via synchronous telemedicine, specifying whether it was audio-visual or audio-only. The type of technology used, such as a secure video platform or telephone, should also be noted.

Patient location at the time of service must be documented, as well as confirmation of informed patient consent for the telemedicine encounter. The medical record should also detail the medical necessity of the service, justifying why the telemedicine modality was appropriate for the patient’s condition. This comprehensive documentation supports the claim during potential payer review and audit processes.