Modifier 95: A Comprehensive Guide to Telehealth Billing

Understanding Modifier 95: A Brief Overview

Modifier 95 is a medical billing code used to indicate that a service was provided via telehealth. This modifier is essential for ensuring that healthcare providers receive appropriate reimbursement for remote services.

Here are the key points about Modifier 95:

• Purpose: Modifier 95 is appended to the CPT or HCPCS code for a service that was conducted through real-time audio and video communication between a healthcare provider and a patient.
• Usage: It’s primarily used for services that mirror in-person visits but are provided remotely, such as consultations, follow-up visits, and behavioral health services.
• Requirements: To use Modifier 95, the telehealth service must meet specific requirements, including using synchronous communication technology. Asynchronous or “store-and-forward” services generally don’t qualify.
• Billing: When Modifier 95 is used correctly, it ensures the claim is processed as a telehealth service and eligible for reimbursement, often under the same rates as in-person care, depending on the payer.

Key Situations for Using Modifier 95

1. Telehealth Visits:
   • • Initial consultations: When a patient is seen for the first time using telehealth technology.
     • Follow-up visits: Subsequent visits with a healthcare provider via telehealth.
     • Established patient visits: When the patient has been seen within the past 3 years.
     • New patient visits: When the patient is new to the practice and is seen via telehealth.
2. Telehealth Consultations:
   • When a healthcare provider consults with another provider about a patient using telehealth.
3. Telehealth Evaluations:
   • When a healthcare provider evaluates a patient’s condition using telehealth.

Important Considerations

• Payer Requirements: Always check with the payer’s specific guidelines to ensure compliance with their rules regarding telehealth services and the use of Modifier 95.
• State and Federal Regulations: Be aware of any state or federal regulations that may impact the use of telehealth services and the application of Modifier 95.
• Documentation: Maintain detailed documentation of telehealth visits, including the date, time, and type of service provided. This documentation can be crucial in supporting reimbursement claims.
• Example of Modifier 95 Usage

If a physician performs a telehealth follow-up visit with an established patient, the billing code would be the appropriate evaluation and management (E/M) code followed by Modifier 95. For instance, if the visit is a level 3 E/M, the billing code would be 99213-95.

Conclusion

By understanding the appropriate use of Modifier 95 for telehealth services, healthcare providers can ensure accurate billing and reimbursement. This modifier is a vital tool in the world of telehealth, helping to streamline the billing process and ensure that providers receive fair compensation for their services.