When to Use Modifier 95 for Telehealth Services

Medical billing modifiers play a crucial role in accurately communicating healthcare service details to payers. Modifier 95 indicates when a medical service is delivered remotely. It differentiates telehealth services from in-person care, ensuring proper processing and reimbursement for virtual encounters. This modifier helps providers report synchronous telemedicine services, clarifying the nature of the encounter for insurance companies.

Understanding Modifier 95

Modifier 95 identifies a synchronous telemedicine service, involving real-time, interactive communication between a healthcare provider and a patient. “Synchronous” means both audio and video components are present and used interactively during the encounter. The American Medical Association (AMA) introduced this modifier in 2017 to help providers accurately report services delivered through telecommunication technology. Its intent was to distinguish audiovisual telehealth services from traditional in-person visits, aiding insurers in processing claims for care provided when the patient and provider are in different physical locations.

Criteria for Proper Application

Proper application of Modifier 95 relies on meeting specific conditions. A fundamental requirement is synchronous, real-time audio and video telecommunication during the patient encounter. This means both visual and auditory components must be interactive and simultaneous, facilitating a live discussion and assessment. Services delivered via telehealth must also be those that can be safely and effectively provided remotely.

Common eligible services include evaluation and management (E/M) services, behavioral health sessions, and certain therapy services. These are typically listed in Appendix P of the CPT manual, indicating codes performable via synchronous audio-video telehealth.

Payer policies significantly influence Modifier 95 acceptance and requirements. For instance, Medicare, as of early 2024, generally no longer requires Modifier 95 on professional telehealth claims. Instead, Medicare relies on specific Place of Service (POS) codes like 02 (telehealth provided other than in patient’s home) or 10 (telehealth provided in patient’s home) to indicate modality and location. However, some commercial payers and Medicaid plans continue to require Modifier 95, and their policies may differ. Providers should always verify individual payer guidelines for compliance and proper reimbursement.

Situations Where Modifier 95 is Not Appropriate

Modifier 95 should not be appended to all telehealth services, as specific communication methods or service types render it unsuitable. Services delivered via asynchronous technology, often called “store-and-forward,” do not qualify. This includes scenarios where medical information is transmitted for later review without a real-time interactive session.

Modifier 95 is also not applicable for audio-only telehealth services. If communication occurs solely through telephone, a different modifier, such as Modifier 93, is typically used, provided the payer allows it.

Furthermore, Modifier 95 is inappropriate for procedural codes or services requiring physical presence, manipulation, or direct patient contact. Services already defined as telehealth within their CPT code description also do not require Modifier 95, as its addition would be redundant. Avoid using Modifier 95 if the payer’s policy explicitly states it is not required or if another modifier is specified for the particular telehealth scenario.

Supporting Documentation

Comprehensive documentation in the patient’s medical record is crucial to substantiate Modifier 95 use. The record must clearly indicate the service was delivered via synchronous audio and video technology, confirming the interactive nature of the encounter. This includes noting the specific platform used, ensuring it is a secure and compliant telehealth system.

Documenting informed patient consent for the telehealth service is also important, aligning with privacy regulations and best practices. The locations of both the patient (distant site) and the provider (originating site) at the time the service was rendered should be recorded. This often involves noting the city and state, and sometimes the specific facility type or whether the patient was in their home.

The medical record must also support the medical necessity of the service provided, just as it would for an in-person visit. The clinical justification for the encounter, including the patient’s condition, the assessment performed, and the treatment plan, should be thoroughly documented.