Did you know that approximately 12.6% of Medicare beneficiaries received telehealth services in the last quarter of 2023 alone? Besides, research showed that after a virtual visit, patients do not require another in-person encounter for up to 90 days. These numbers are enough to prove that telehealth is key to lowering the burden on the healthcare system by converting routine in-person visits to remote interactions.
However, billing for these services has its unique challenges. Modifier 95 is one of the telehealth-specific modifiers that physicians struggle with. This guide covers when to use it and what to document to help you ensure accurate reimbursement.
So, without further ado, let’s get started!
Modifier 95 – Description
Modifier 95 indicates that the rendered healthcare service was performed using a HIPAA-compliant synchronous telehealth technology. That is, the technology enabled real-time, interactive audio and video communication.
A national research survey found that:
- Individuals’ willingness to utilize telehealth services increases from 64.5% to 83% if the service is insurance-covered or cheaper.
- Adults aged 55 or older are less willing to use telehealth services than those younger than 55 years.
Accurate Usage Guidelines for Modifier 95
The following are some of the key reporting guidelines for accurate usage of modifier 95:
Documentation Requirements
Detailed documentation plays an integral role in getting your claim for telehealth services (with modifier 95) approved on the first try. Thus, your documentation must contain the following:
- Use relevant place of service (POS) codes to document the physical location of the patient and the provider at the time of visit.
- Explicitly mention that the physician performed the service using a HIPAA-compliant, real-time, interactive audio and video platform (synchronous).
- If you are billing a timed code (e.g., psychotherapy, 30 minutes represented by CPT code 90833), do not forget to include the details about the total time spent and the activities performed.
- Justify the medical necessity for the delivery of care services via telehealth. Also include limitations imposed by the remote setting (if any).
Understand When to Append Modifier 95
Use this modifier only if:
- The physician conducted the session using a HIPAA-compliant, real-time, interactive audio and video (synchronous) system.
- You are billing for an approved telehealth service code. It can be office visits, speech therapy, psychotherapy, or others.
Know When NOT to Use Modifier 95
Avoid reporting care service with 95, if:
- The visit lacks the video component for real-time visual assessment. Simply put, the physician rendered the telehealth service via an audio-only platform.
- The physician utilized an asynchronous system to transmit medical images or data without a real-time, interactive provider discussion.
- The service was purely technical, such as lab or imaging.
Appropriate Use Cases for Modifier 95
Discussed below are some of the real-world clinical scenarios where modifier 95 applies:
Established Patient’s Chronic Care Follow-up
Picture a 60-year-old male patient with type 2 diabetes. He is an established patient of an endocrinologist and was scheduled for a follow-up visit.
The goal of the encounter is to review the patient’s recent lab results (glucose logs, A1C), discuss side effects from the current medication regimen, and adjust insulin dosage. Besides, the patient’s adherence to the exercise and diet plan will be evaluated.
However, the patient lives in a rural area and traveling to the clinic is not an option due to inclement weather. Thus, the physician conducts the visit securely using a synchronous video and audio platform.
Here, modifier 95 will be reported with CPT code 99213.
Individual Psychotherapy Session
Assume a licensed clinical psychologist who had a scheduled meeting with a 20-year-old male patient for weekly individual psychotherapy (CPT code 90834). However, the patient is currently away at college in a different city, but requires continuity of care to manage his anxiety disorder.
As a result, the psychologist renders the 45-minute therapy session via an interactive video conferencing system. The session includes real-time discussion, cognitive behavioral exercises, and emotional assessment.
The psychotherapist will report CPT code 90834 with modifier 95 to bill for the service.
New Patient Consultation for Remote Diagnosis
Imagine a 5-year-old girl with complex neurological symptoms. She lives several states away. Thus, the parents asked a pediatric specialist, who is also licensed in the state she resides in, to provide an initial diagnostic consultation via a two-way, real-time video link.
During the telehealth encounter, the physician performs a detailed patient history intake, interviews the parents, and visually assesses the child’s gait, tone, and cognitive responses.
Here, the pediatric specialist will report CPT code 99204 with modifier 95.
Final Thoughts
Telehealth is not just an alternative, but a gateway to quality care for people living in remote areas, traveling due to other commitments, or confined to their homes. But physicians often find it challenging to get paid for these services.
Thus, this guide explained modifier 95 to help you understand when you can append it to ensure you get paid for your real-time, interactive audio and video telehealth encounters. Hopefully, with this guide, your struggle to bill telehealth services will come to an end. However, if you still stumble, feel free to partner with a professional medical billing company like NeuraBill.
FAQs
What is the difference between modifiers 95 and 93?
Modifier 95 indicates real-time, video, and audio encounters. On the other hand, modifier 93 represents audio-only communication.
What is the difference between GT and 95 modifiers?
Modifier GT and 95 both represent real-time synchronous video and audio telehealth visits. The only distinction is that not all payers accept modifier 95. Thus, before submitting a claim for telehealth service, ask the relevant payer which modifier they prefer.
Can I use modifiers 95 and 25 together?
Yes, you can report a telehealth service with 95 and 25 modifiers. The general rules say to list payment modifiers first. Thus, here you should report modifier 25 (representing a significant and separately identifiable E/M service) before 95.
Is modifier 95 still valid in 2025?
Yes, Medicare and some other private payers are still accepting telehealth services with 95.
Does modifier 95 reduce reimbursement?
No, 95 is not a payment modifier and does not impact reimbursement. It is an informational modifier that highlights that service was rendered via a real-time audio and video telecommunication system.
Can you bill modifier 95 with POS 11?
Physicians who were rendering telehealth services in the office during COVID-19 were allowed to use POS 11 with 95. Thus, we recommend that you review the payer guidelines before using POS 11.
Does Medicaid accept modifier 95?
Yes. The Medicaid program of several states accepts modifier 95 on telehealth service claims. For example, New York Medicaid and Medi-Cal (California Medicaid) accept it.
Does Aetna accept modifier 95?
Yes. Aetna accepts both modifiers GT and 95. However, these modifiers must be reported with the POS code 02.
Does Humana accept modifier 95?
Yes. Humana also accepts this modifier on telehealth claims.
Does UHC accept modifier 95?
Like most notable commercial payers, UnitedHealthcare (UHC), too, accepts the 95 modifier. However, it must be reported with POS codes 02 and 10.
