Modifier 95: Appropriate Use
Basics of Modifier 95
Modifier 95: Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system. The modifier 95 was introduced in 2017 and is different from CPT or procedure codes, and describes the claim. Synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified healthcare professional and a patient who is located at a distant site from the physician or other qualified healthcare professional.
The totality of the communication of information exchanged between the physician or other qualified healthcare professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via face-to-face interaction.
Modifier 95 may only be appended to the services listed in Appendix P. Appendix P is the list of CPT codes for services that are typically performed face-to-face but may be rendered via a real-time (synchronous) interactive audio and video telecommunications system.
Place of Service
A frequent area of confusion for billing telemedicine CPT codes was whether the place of service changes. If the provider is at the facility but the patient is at home, is the place of service still 11? As of January 1, 2017, the recommended Place of Service for telemedicine was 02. This references a location where the service is received through telemedicine technology. Not all payers require the 02 place of service to bill a telemedicine claim, but it’s good information to have if you receive remittance advice indicating that the Place of Service is incorrect.
In most cases, billing for telemedicine looks a whole lot like billing for in-person evaluation and medication management. The biggest difference is that you will add a modifier. There are three potential modifiers that tag a claim as telehealth: GT, GQ, and 95.
95 Modifier vs. GT Modifier
A GT modifier is an older coding modifier that serves a similar purpose as the modifier 95. There is considerable overlap between situations for using GT and 95. CMS recommends 95, different companies have varying standards for which codes to be billed. It is a good idea to check with the plans before billing. Rules vary by payer, with some requiring one while others will prefer the other. It’s pretty difficult to predict, so asking is the right way to go. Reimbursement should be the same regardless of the modifier, but that might be a good question to ask as well.
Modifiers © Copyright 2021 American Medical Association
For accurate Mental/Behavioral Health medical billing, knowing your CPT codes along with modifiers is the most important thing. In our blog series of ‘Know Your Codes’ or ‘KYC,’ we have discussed the most common CPT codes in detail and when to use them. E2E Medical Billing Services is known for its accurate Mental/Behavioral Health medical billing and coding. To know more about our services call us at 888-552-1290 or write to us at info@e2eMedicalBilling.com