Medical billing can be complex, especially when dealing with telehealth services. One crucial component of telehealth billing is Modifier 95, which ensures healthcare providers receive proper reimbursement for virtual consultations. In recent years, telehealth services have grown significantly, especially after the COVID-19 pandemic, leading to new billing regulations and requirements. Modifier 95 plays a key role in distinguishing synchronous (real-time audio-video) telehealth services from in-person visits. In this guide, we will cover everything about Modifier 95, including when to use it, how it affects reimbursement, how to apply it correctly, and the differences between Modifier 95 and other telehealth modifiers. We will also discuss common mistakes, CPT codes that require Modifier 95, and best practices for claim submissions.
What is Modifier 95? – Modifier 95 Description
Modifier 95 is a medical billing code used to indicate that a healthcare service was delivered via telehealth using real-time, interactive audio-video technology. This modifier allows healthcare providers to differentiate between in-person and virtual services, ensuring that payers correctly process telehealth claims.
This modifier is attached to CPT (Current Procedural Terminology) codes to signify that the service was provided through telecommunication rather than a face-to-face visit. Many insurance companies, including Medicare and Medicaid, recognize Modifier 95 for telehealth reimbursement.
Purpose of Modifier 95 in Medical Billing
Modifier 95 serves several essential functions in medical billing:
- Ensures Proper Reimbursement – Insurance companies recognize services provided through telehealth and compensate providers accordingly.
- Helps Distinguish Telehealth from In-Person Visits – This modifier clarifies that the service was conducted remotely rather than in a physical setting.
- Expands Access to Healthcare – By supporting telehealth billing, Modifier 95 allows more patients to receive care, especially in rural areas.
- Supports Regulatory Compliance – Using Modifier 95 correctly ensures compliance with Medicare and private insurer policies regarding telehealth services.
Also Read: Role of AI in Medical Billing
When Should You Use Modifier 95?
Modifier 95 should be used when:
- The service is provided via a real-time, interactive audio-video communication platform.
- The CPT code is on the approved list of telehealth services.
- The provider and patient are in separate locations during the service.
- The payer (insurance company, Medicare, or Medicaid) recognizes Modifier 95 for telehealth reimbursement.
- The telehealth consultation meets the requirements of a covered medical service under telehealth regulations.
When Should You NOT Use Modifier 95?
Do not use Modifier 95 in the following cases:
- The service is provided in person rather than via telehealth.
- The interaction was audio-only (telephone-based service) without a video component.
- The payer requires a different telehealth modifier, such as GT or FQ.
- The service does not qualify for telehealth reimbursement under insurance guidelines.
- The claim already includes a POS (Place of Service) code that negates the need for Modifier 95.
How Modifier 95 Affects Telehealth Services
Telehealth has transformed patient care by allowing remote consultations with physicians and specialists. Modifier 95 plays a significant role in ensuring that these virtual visits are recognized as legitimate medical services.
Key Impacts on Telehealth:
- Expands coverage for virtual care – Many insurers recognize telehealth services as equivalent to in-person visits when Modifier 95 is used.
- Improves access to specialists – Patients in rural areas or with mobility challenges can connect with healthcare providers without needing to travel.
- Reduces healthcare costs – Virtual consultations eliminate expenses related to transportation and clinic overhead.
- Encourages continuity of care – Patients can follow up with their providers more easily through telehealth platforms.
How Modifier 95 Affects Reimbursement
Proper use of Modifier 95 ensures fair and timely reimbursement for telehealth services. However, each payer has its own policies regarding reimbursement rates for virtual visits.
Key Considerations for Reimbursement:
- Medicare and Medicaid reimburse many telehealth services at the same rate as in-person visits when Modifier 95 is used.
- Private insurance companies may have different rules, requiring verification of specific payer policies.
- Incorrect or missing Modifier 95 can lead to claim denials, delays, or reduced reimbursement.
- Some insurers require additional documentation to prove that the service met telehealth requirements.
How to Apply Modifier 95 on Claims
To ensure correct medical billing and avoid claim rejections, follow these steps when applying Modifier 95:
- Check if the CPT code is eligible for telehealth – Verify that the service is listed as an approved telehealth procedure.
- Use the correct Place of Service (POS) code – Commonly used POS codes include:
- POS 02 (Telehealth provided outside the patient’s home)
- POS 10 (Telehealth provided in the patient’s home)
- Attach Modifier 95 to the CPT code – This signals that the service was performed via interactive telehealth.
- Verify payer guidelines – Some insurers may require a different modifier or additional documentation.
Modifier 95 and Place of Service (POS) Codes
Place of Service (POS) codes are essential in medical billing as they indicate where a service was provided. When using Modifier 95 for telehealth services, the correct POS code must also be included to ensure claim approval.
POS 02 – Telehealth Provided Other than in Patient’s Home
POS 02 is used when telehealth services are provided outside the patient’s home, such as in a clinic or hospital setting. When billing with Modifier 95, using POS 02 helps insurers recognize the service as a valid telehealth consultation.
POS 10 – Telehealth Provided in Patient’s Home
POS 10 is used when a telehealth service is provided while the patient is at home. This code helps distinguish between virtual visits that occur in medical facilities versus those conducted from a patient’s residence.
POS 11 – Office Setting
POS 11 is typically used for in-person visits at a provider’s office. However, some insurers allow POS 11 with Modifier 95 when the provider is in their office, but the patient is remote. This can vary by payer, so it’s important to check with specific insurance guidelines before applying this combination.
Other POS Codes Relevant to Telehealth
- POS 21 – Inpatient Hospital: Used if a provider conducts a telehealth visit while the patient is admitted to a hospital.
- POS 31 – Skilled Nursing Facility (SNF): Used for virtual consultations when the patient is in a nursing facility.
- POS 32 – Nursing Facility: Applied when a telehealth service is provided to a patient residing in a nursing home.
Dig Deeper: POS 11 vs. POS 22 in Medical Billing
Modifier 95 vs. Other Telehealth Modifiers
| Modifier | Purpose | Used for Telehealth? | Key Difference |
|---|---|---|---|
| Modifier 95 | Synchronous telehealth (real-time audio-video) | ✅ Yes | Confirms interactive video communication |
| Modifier GT | Telehealth via interactive audio-video | ✅ Yes | Used mainly by Medicare Advantage plans |
| Modifier GQ | Telehealth via asynchronous communication | ✅ Yes | Used for store-and-forward technology (not real-time) |
| Modifier FQ | Audio-only telehealth services | ✅ Yes | Used when no video component is available |
CPT Codes That Require Modifier 95
Modifier 95 applies to various Evaluation and Management (E/M), mental health, and therapy services conducted via telehealth. Below are some of the commonly billed CPT codes that require Modifier 95.
CPT Code 90834 with Modifier 95
CPT Code 90834 refers to a 45-minute psychotherapy session. When conducted via telehealth, it should be billed as 90834-95 to ensure correct reimbursement. This modifier tells insurance companies that the session was performed remotely but still meets the necessary billing criteria.
CPT Code 90837 with Modifier 95
CPT Code 90837 covers a 60-minute psychotherapy session. If performed through telehealth, it should be billed as 90837-95. Adding Modifier 95 ensures that the service is recognized as a virtual consultation and qualifies for telehealth reimbursement under applicable guidelines.
Also Read: CPT Codes for Labs
CPT Code 99201-99215 with Modifier 95
These codes refer to Evaluation & Management (E/M) visits, which include consultations, follow-ups, and medical assessments. When conducted via telehealth, they should be billed with Modifier 95 (e.g., 99213-95) to indicate the remote nature of the service. Using this modifier ensures proper claim approval and reimbursement for virtual consultations.
CPT Code 99441-99443 with Modifier 95
These CPT codes cover telephone-based Evaluation & Management (E/M) services. They apply when a healthcare provider offers medical advice over the phone without an in-person visit. Billing with Modifier 95 ensures that these services are correctly identified as telehealth consultations and eligible for reimbursement.
CPT Code 99457-99458 with Modifier 95
These CPT codes represent Remote Patient Monitoring (RPM) services. They apply when a provider remotely monitors a patient’s health data, such as heart rate or blood pressure, using digital tools. Adding Modifier 95 confirms that these monitoring sessions were conducted virtually and qualify for reimbursement under telehealth policies.
Advantages of Using Modifier 95 in Medical Billing
Ensures Telehealth Reimbursement
Modifier 95 helps healthcare providers receive payment for virtual services. Without it, insurance companies might reject claims for remote consultations.
Supports Telehealth Expansion
As telemedicine grows, Modifier 95 allows practitioners to offer remote care while maintaining compliance with billing regulations.
Improves Access to Care
Patients who cannot visit a clinic in person such as those in rural areas can still receive medical services via telehealth, thanks to Modifier 95.
Reduces Administrative Errors
Using Modifier 95 correctly helps avoid claim denials and ensures smooth processing of telehealth reimbursements.
Common Mistakes When Using Modifier 95 in Medical Billing
Applying Modifier 95 to In-Person Services
Modifier 95 should only be used for telehealth services. Applying it to an in-person visit can lead to claim rejections.
Using Modifier 95 with Incorrect CPT Codes
Not all CPT codes are eligible for Modifier 95. Providers should check billing guidelines to ensure the correct use of this modifier.
Failing to Include the Correct Place of Service (POS) Code
Modifier 95 should be used alongside the appropriate POS code, such as POS 02 (Telehealth). Incorrect POS coding can delay or deny claim processing.
Using Modifier 95 and GT Together
Modifier 95 and GT Modifier both indicate telehealth services, but they should not be used together. Most insurance providers now prefer Modifier 95 over GT.
Conclusion
Modifier 95 plays a crucial role in medical billing by ensuring that telehealth services are properly recognized and reimbursed. It applies to various CPT codes related to Evaluation & Management, psychotherapy, and remote patient monitoring. When used correctly, it helps providers get paid for virtual consultations, expands telehealth access, and reduces claim denials. However, using it incorrectly such as applying it to in-person services or pairing it with the wrong place of service (POS) code can lead to billing issues. By understanding when and how to use Modifier 95, healthcare providers can streamline their telehealth billing processes and ensure compliance with reimbursement guidelines.
FAQs
Do you use Modifier 95 or GT for telehealth?
Modifier 95 is now preferred over GT for telehealth services. While both indicate a telehealth visit, many insurers, including Medicare, have transitioned to using Modifier 95 for billing.
What is Modifier 95 used for?
Modifier 95 is used to indicate that a medical service was provided via telehealth. It ensures that remote consultations are properly documented and reimbursed by insurance providers.
Is Modifier 95 still valid in 2024?
Yes, Modifier 95 remains valid in 2024 and continues to be widely used for telehealth billing. Many insurance providers, including Medicare and private insurers, recognize it for virtual medical services.
Can I use Modifier 95 and Modifier 25 together?
Yes, Modifier 95 and Modifier 25 can be used together, but only when appropriate. Modifier 25 is applied when a separate and significant Evaluation & Management (E/M) service is performed during the same visit. Both modifiers must be justified with proper documentation.
What is CPT Code 90837 with Modifier 95?
CPT Code 90837 represents a 60-minute psychotherapy session. When performed via telehealth, it is billed as 90837-95 to indicate that the session was conducted remotely and qualifies for telehealth reimbursement.
