Modifier 95: A Guide To Telehealth Billing

By Author: Albert Brown
Total Articles: 76
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Key Points About Modifier 95:

Purpose: Modifier 95 is appended to the CPT or HCPCS code for a service 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, 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.
Common Use Cases for Modifier 95:

Telehealth Visits: Initial consultations, follow-up visits, established patient visits, and new patient visits.
Telehealth Consultations: When a healthcare provider consults with another provider about a patient using telehealth.
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.

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