Modifier 95 for Telehealth Billing: When and How to Use It
Telehealth has redefined the way providers and patients connect, offering convenience and continuity of care from virtually anywhere. But while virtual visits are simpler for patients, your telehealth billing often brings added complexity. One area where practices face repeated denials is the incorrect use of billing modifiers—especially Modifier 95.
Adding Modifier 95 ensures the claim is recognized as a telehealth service, prevents confusion with in-person visits, and helps practices protect their revenue.
This guide breaks down when to use Modifier 95, when not to use it, and the exact steps to bill it correctly, so you can streamline reimbursement and avoid claim denials.
What Is Modifier 95?
Modifier 95 is a CPT billing modifier that confirms a service was performed through real-time, interactive audio and video technology. When appended to an approved CPT or HCPCS code, it tells payers the visit was virtual, not in-person.
While Medicare often relies on Place of Service (POS) codes such as 02 or 10, many commercial payers still require Modifier 95 to process telehealth claims.
When to Use Modifier 95
Use Modifier 95 for any service conducted via synchronous telehealth technology. Key scenarios include:
Initial Consultations – First-time telehealth visits with a new patient.
Follow-up Visits – Ongoing care, treatment reviews, or recovery checks conducted virtually.
Established Patient Visits – Returning patients (within the past 3 years) seen via telehealth.
New Patient Visits – First-time encounters for patients new to your practice.
Telehealth Consultations – Virtual provider-to-provider discussions regarding a patient’s case.
Telehealth Evaluations – Clinical evaluations performed through live video technology.
When NOT to Use Modifier 95
Avoid Modifier 95 in cases where the requirements for real-time audio and video are not met. Common mistakes include:
Audio-Only Services → Use Modifier 93 instead.
In-Person Visits → Modifier 95 is not applicable.
Store-and-Forward Services → Recorded data reviews are not synchronous telehealth.
Non-Approved Codes → If the CPT or HCPCS code isn’t on the payer’s telehealth-approved list.
When Payer Doesn’t Require It → Some insurers, including Medicare in certain scenarios, rely only on POS codes.
Step-by-Step Guide to Using Modifier 95
Billing with Modifier 95 requires precision. Here’s a clear process:
1.Verify Telehealth Service Eligibility
Confirm that the CPT or HCPCS code is approved for telehealth reimbursement. Payer guidelines change often, so always check the most recent updates.
2. Check Patient Coverage
Verify the patient’s insurance plan covers telehealth services and note copays, deductibles, or coinsurance to avoid surprises.
3. Confirm Provider Eligibility
Some payers only reimburse telehealth for certain provider types (e.g., physicians, NPs, licensed therapists).
4. Choose the Correct CPT/HCPCS Code
Use the most accurate code for the service provided—such as office visits, psychotherapy, or diagnostics. An incorrect HCPCS code may trigger denials.
5. Append Modifier 95
Add Modifier 95 to confirm the service was provided through synchronous video telehealth.
6. Use the Correct POS Code
POS 02 → Telehealth outside the patient’s home
POS 10 → Telehealth inside the patient’s home
7. Document the Encounter
Proper notes must include patient consent, technology used, session duration, clinical details, and diagnosis. This ensures compliance and supports audit readiness.
8. Submit the Claim
Claims may be filed electronically or through the CMS-1500 form. Double-check CPT/HCPCS code, POS, and Modifier 95 before submission.
9. Monitor Claim Status
Always follow up. If denied, review the explanation of benefits (EOB) to identify errors (e.g., missing modifiers, wrong codes) and resubmit or appeal.
10. Consider Outsourcing
Because payer rules change frequently, many practices reduce denials by outsourcing telehealth billing and coding services. Expert billers track CMS updates, payer requirements, and compliance changes—helping you get paid faster.
Final Thoughts
Modifier 95 is a small addition that makes a big difference in your telehealth billing success. Using it correctly helps providers avoid denials, comply with payer rules, and receive proper reimbursement.
For error-free claims and reliable revenue flow, consider outsourcing telehealth billing and coding services to experts like 24/7 Medical Billing Services. With the right partner, you can focus on patient care while leaving billing complexities behind.
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FAQs About Modifier 95
Q1. Do all payers accept Modifier 95?
Most commercial payers do, but policies vary. Always confirm with the payer.
Q2. Is Modifier 95 required for behavioral health telehealth?
Yes, in most cases. Many plans mandate Modifier 95 for virtual behavioral health visits.
Q3. How is Modifier 95 different from Modifier GT?
Modifier 95 is more widely used today. Modifier GT is accepted by limited payers only.
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