For 72% of U.S. physicians, implementing telehealth services is the easy part. The real challenge is billing for them. Are you also looking for a way to file accurate claims for these services? We might have the perfect solution for you — Modifier 95!
Introduced in 2017 by the American Medical Association (AMA), this CPT modifier helps healthcare providers report synchronous telemedicine services. But when should you apply this modifier, and does every payer accept it in all situations? If you have similar questions, read on to make sure your telehealth claims are coded correctly and paid on time.
Modifier 95 – Description
Does modifier 95 sound complex? Let’s make it easy to understand! As mentioned in the introduction, this two-digit code refers to synchronous telemedicine services. But what does this mean? A synchronous telehealth service is the real-time interactive communication between a doctor and a patient. It usually takes place via a reliable telehealth platform.
To put it simply, billing specialists append this modifier to appropriate CPT or HCPCS codes when healthcare providers use audio and video technology to assess, diagnose, and treat patients in remote settings.
In short, this modifier helps insurance companies distinguish audiovisual health services from in-person visits. These may include:
- Initial consultations
- Follow-up visits
- Therapy sessions
- Remote patient monitoring
The description sounds simple, right? But there is a catch! Medicare no longer requires this modifier on professional telehealth claims. We will discuss this further in the accurate usage guidelines. For now, let’s focus on modifier 95’s correct application.
Modifier 95 – Examples
Here are three specific real-world examples to help you understand when to use modifier 95 in telehealth billing:
Reporting Virtual Psychotherapy
Let’s start with a basic example of teletherapy! Suppose a 24-year-old man with severe social anxiety chooses teletherapy with a licensed professional due to his remote location. A certified psychologist employed by a hospital provides weekly psychotherapy sessions to help him manage his anxiety.
He spends at least 60 minutes interacting with the patient, using various techniques to help him overcome and manage his problems. The institution bills for this weekly interactive audiovisual psychotherapy using CPT code 90837 and appends modifier 95 to indicate that the session was conducted online.
Reporting Virtual End-Stage Renal Disease (ESRD) Management
Let’s assume a 1-year-old toddler with ESRD is enrolled in a remote management program due to her location. She lives in a rural area, making it difficult for her parents to take her to a hospital for monthly in-person visits. A pediatric nephrologist, Dr. Garcia, manages the patient’s monthly care, conducting all four required sessions online.
She monitors the toddler’s weekly lab results, symptoms, fluid balance, and the effectiveness of medication and dialysis. Suppose the patient has a commercial insurance plan that accepts modifier 95. Therefore, Dr. Gracia reports this procedure (CPT code 90951) with this modifier, helping the payer distinguish these virtual meetings from in-office visits.
Reporting Virtual Speech Therapy Sessions
Let’s consider a virtual speech therapy example! Suppose a hospital-employed speech-language pathologist provides group therapy to two children with similar speech and hearing impairments. Due to their geographic locations, he conducts these sessions virtually using reliable audio and video technology.
The therapist focuses on improving their speech, language, and hearing abilities through interactive exercises and techniques. The hospital then bills for these services using CPT code 92508 with modifier 95.
Accurate Usage Guidelines for Modifier 95
Modifier 95 is essential for filing telehealth claims. However, you should not apply it to every code. Want to avoid serious consequences? Familiarize yourself with this modifier’s correct and incorrect uses to ensure proper claim submission.
Accurate Uses of Modifier 95
Apply this modifier only to:
- Synchronous (real-time audio and video) telehealth services.
- The approved list of telehealth services (e.g., office visits, psychotherapy, speech therapy, and more)
Inaccurate Uses of Modifier 95
Do not use this modifier for:
- Telephone calls (audio-only sessions)
- In-person visits
- Telehealth services that require a different reporting method (such as POS codes or another modifier based on payer requirements)
Maintain Complete Documentation
Insurance companies require proper proof of virtual sessions with modifier 95. Therefore, document the following details:
- A statement confirming the visit was conducted online.
- Patient consent for the telehealth service.
- Details of the telehealth platform used (it should be HIPAA-compliant)
Verify Payer-Specific Rules
Since the beginning of last year, Medicare no longer requires modifier 95 for professional telehealth services. Instead, providers must use Place of Service (POS) codes 02 or 10 to indicate the patient’s location.
However, you can still use this modifier for institutional billing, such as outpatient therapy services provided by hospital-employed therapists via telehealth. Another thing to remember? Commercial payers frequently update their policies, and their requirements for modifier 95 may differ.
Therefore, always verify each insurance company’s rules before applying this modifier to the appropriate CPT or HCPCS code to avoid claim denials.
Summary
To wrap things up, the popularity of telemedicine is undeniable, and these services will only continue to grow. Therefore, healthcare providers and billing professionals should understand how to bill them accurately. This is exactly why we simplified modifier 95 for you.
We covered what it reports (synchronous telehealth services), provided three specific real-world examples, and walked you through accurate usage guidelines to help you file clean claims. We also discussed the ever-changing payer rules, including Medicare’s latest updates on modifier 95 and POS codes for institutional and professional billing.
So, follow our tips and use this modifier accurately for timely payments.
