Modifier 95 for Telehealth Billing: When and How to Use It

Telehealth has transformed the way patients and providers connect, offering convenience, accessibility, and continuity of care from virtually anywhere. Though telehealth makes healthcare delivery easier, billing for these services is often more complex. One of the most common sources of confusion for providers and billers is the correct use of modifiers, especially Modifier 95. When Modifier 95 is included on a claim, it confirms that the care was given through telehealth. This ensures the service is billed under the proper rules to prevent confusion with in-person visits and help practices avoid unnecessary revenue loss.

This blog explains the key situations where Modifier 95 applies, when it should not be used, and the step-by-step process to bill it correctly so that you can reduce denials and streamline your telehealth billing.

Understanding Modifier 95 for Telehealth Billing

Modifier 95 is a CPT billing add-on that signals a healthcare service was provided via real-time, interactive audio and video telehealth. When appended to an approved CPT or HCPCS code, it indicates to payers that the encounter was virtual rather than in person. This distinction is essential for accurate claims processing and reimbursement. Though Medicare has shifted to relying on Place of Service (POS) codes like 02 or 10, many commercial and private payers still require modifier 95 to identify and pay for telehealth services properly.

When to Use Modifier 95 for Telehealth Billing

Modifier 95 should be used when a healthcare service is provided through real-time audio and video technology instead of face-to-face. It ensures that the payer identifies the service as a telehealth visit and reimburses it correctly. Below are the key situations where Modifier 95 applies--

• Initial Consultations

Modifier 95 should be added when a patient is seen for the very first time using telehealth technology, as it confirms that the consultation was conducted virtually.

• Follow-up Visits

Use Modifier 95 for follow-up appointments that take place through telehealth, such as when a provider checks in on a patient’s ongoing treatment plan or recovery progress.

• Established Patient Visits

When a patient who has already visited the practice in the past three years connects with the provider using telehealth, Modifier 95 should be applied to the billing code.

• New Patient Visits

If a patient is completely new to the practice and attends their first appointment virtually, Modifier 95 should be included to show that the visit was conducted through telehealth.

• Telehealth Consultations

When one healthcare provider consults with another provider about a patient’s condition using telehealth, Modifier 95 should be used to indicate that the consultation occurred via a virtual platform.

• Telehealth Evaluations

If a provider evaluates a patient's condition using synchronous telehealth technology, Modifier 95 should be appended to the claim to ensure that the evaluation is reimbursed adequately as a telehealth service.

When Not to Use Modifier 95 for Telehealth Billing

Modifier 95 should not be used when the service does not meet the requirements of a real-time audio and video telehealth encounter. Inappropriate use of this modifier can cause claim denials or result in incorrect payments.

• Audio-Only Services

Modifier 95 should not be applied to audio-only services, such as telephone calls, as these services require Modifier 93 instead.

• In-Person Services

If the patient and provider meet face-to-face in a physical location, Modifier 95 should not be used, as the service is not considered telehealth.

• Store-and-Forward Services

Modifier 95 should not be appended to asynchronous telehealth services, such as when recorded images, videos, or other patient data are sent for later review.

• Non-Approved CPT Codes

If the CPT or HCPCS code is not listed as an approved telehealth code by Medicare or the specific payer, Modifier 95 should not be used on the claim.

• When Payer Does Not Require It

Some payers, including Medicare in certain situations, may rely only on Place of Service codes like 02 or 10 to process telehealth claims, and in those cases, Modifier 95 should not be added.

How to Use Modifier 95 in Telehealth Billing

Billing for telehealth services requires careful attention to detail, as it can lead to claim denials or payment delays. Below is a detailed step-by-step guide to ensure Modifier 95 is applied correctly in telehealth billing:

• Verify Telehealth Service Eligibility

The first step is to check whether the service you want to bill is approved for telehealth by CMS or the insurance payer. The reason is that not every procedure code is eligible for telehealth reimbursement, and payers may update their approved telehealth lists frequently. Thereby, it is important to review the latest payer guidelines before billing to ensure that you only submit claims for services that qualify.

• Confirm Patient Eligibility and Coverage

It is equally important to verify if the patient's insurance plan covers telehealth services. Some health plans cover a wide range of telehealth visits, while others may only cover specific services. You should also confirm whether the patient is responsible for any copays, coinsurance or deductibles to avoid any payment surprises later.

• Check Provider Eligibility

It is crucial to note that not all healthcare providers are eligible to deliver telehealth services under payer rules. Some payers limit telehealth reimbursements to specific provider types, such as physicians, nurse practitioners, or licensed therapists. Before submitting a claim, always confirm that the provider is authorized to perform the telehealth service for that insurance plan.

• Select the Correct CPT/HCPCS Codes

Once eligibility is confirmed, you must select the most accurate CPT or HCPCS code for the service provided. This step is crucial as the code directly impacts reimbursement. For example, office visits, psychotherapy, and diagnostic services each have different CPT codes. Using the wrong code can cause claim denials or underpayments.

• Append Modifier 95

After choosing the correct code, add Modifier 95 to indicate that the service was performed through synchronous, real-time audio and video technology. This modifier tells the payer that the service was not delivered in person but still qualifies for telehealth reimbursement. Without Modifier 95, your claim could be denied as incomplete or incorrect.

• Use the Correct POS Code

In addition to the CPT code and Modifier 95, the claim must include the appropriate POS code. The two most common codes are POS 02 for telehealth services provided outside of the patient’s home, and POS 10 for telehealth services provided in the patient’s home. Using the wrong POS code may lead to claim rejections or incorrect payment amounts.

• Document the Telehealth Encounter Properly

Accurate and detailed documentation is essential for telehealth billing compliance. The record should include patient consent for telehealth, the type of telecommunication used (such as audio-video), the date and time of the visit, the duration of the encounter and detailed clinical notes with diagnosis and treatment information. Proper documentation protects providers in case of audits and ensures transparency in billing.

• Submit the Claim

Once all the details are in place, the claim can be submitted electronically through the payer's portal or using the CMS-1500 claim form. Before submission, double-check that the CPT/HCPCS code, Modifier 95 and POS code are included correctly. Submitting accurate claims the first time reduces delays and increases the chances of faster reimbursements.

• Monitor Claim Status

After submission, it is essential to follow up on the claim to see whether it was accepted, rejected or denied. If the claim is denied, carefully review the explanation of benefits (EOB) or the denial reason. Errors such as missing modifiers, incorrect codes, or eligibility issues should be corrected quickly, and the claim should be resubmitted or appealed when necessary.

• Outsource Telehealth Billing and Coding Services

As telehealth billing guidelines often change and vary across different payers, many healthcare providers struggle with errors and compliance challenges. Outsourcing telehealth billing and coding services to an experienced billing company like 24/7 Medical Billing Services can help providers stay compliant, reduce denials and improve revenue flow. Professional billing experts keep up with the latest CMS and commercial payer requirements, allowing providers to focus on delivering quality patient care instead of dealing with billing complexities.

FAQs

Q1. Do all insurance companies accept Modifier 95?

Most do, but acceptance depends on the payer’s telehealth policy.

Q2. Is Modifier 95 required for behavioral health telehealth visits?

It is required for most behavioral and mental health telehealth claims.

Q3. How does Modifier 95 differ from Modifier GT?

Modifier 95 is more widely used today, whereas GT is accepted by some payers only.