Modifier 95 is a CPT code utilized in medical billing to denote a service rendered through telehealth. It is appended to the primary procedure code, indicating the healthcare provider and patient interaction. It is occurred via an interactive audio and video communication system. This modifier is crucial because it ensures that telehealth services are accurately identified. It allows payers to recognize and reimburse the claim appropriately. By employing the code, healthcare providers can effectively document telemedicine visits. In this blog post, we will find the documentation of modifier 95 and provide further information regarding its proper application.
What is Modifier 95?
Modifier 95 functions as a billing code that indicates a healthcare service was provided through telehealth, utilizing real-time, interactive audio and video technology. When attached to a procedure code, it conveys to insurers that the patient and provider were not physically together in the same location during the service. It allows insurers to effectively process and reimburse telehealth claims because they must comply with their particular policies regarding virtual care. Although the ramifications of this modifier are substantial, many individuals remain unaware of its significance. For optimized revenue cycle management through our team of expert medical coders, contact us at MAVA Care.
Modifier 95 Reimbursement
It is used in medical billing to show that a service was given through telemedicine. This means that a patient receives healthcare remotely using audio and video technology. Adding this modifier is important for insurance claims that the service was not done in person. It is done through telecommunication methods. However, reimbursement for services with this code depends on different factors. These include the specific payer’s policies and the type of telehealth service provided. Although it seems straightforward, there are many details to consider.
1.Medicare and Medicaid
These programs usually apply to telehealth services, such as the treatment given in a face-to-face encounter. As long as the service is one of the covered telehealth services, such a code is added. Some Medicaid plans do not allow coverage policies to be transferred between states.
2.Commercial Payers
Every insurance company has different policies when it comes to telehealth reimbursement. In some instances, they may reimburse the same as they would in-person services; in other cases, though rates vary, certain requirements may need to be fulfilled.
3.Documentation Requirements
Most accounts require detailed documentation for reimbursement of telehealth services. It would include the type of telehealth platform used, consent by the patient, and a summary of the services provided.
4.Place of Service (POS) Code
It is commonly used with a POS code specific to telehealth, typically POS 02 or POS 10, so payers can recognize the service location, which might be pertinent in determining the payment rate.
How is 95 Modifier used for Telehealth Services?
- Before beginning telehealth services, ensure the patient’s insurance policy covers telemedicine mental health treatments. Check the plan’s coverage or contact the insurer directly for clarification.
- Obtain prior authorization for telemedicine mental health treatments if the patient’s insurance plan requires it. This usually entails requesting the insurance carrier, describing the reasons for telehealth, and the services to be given.
- Maintain detailed records for each telehealth encounter, particularly the date, time, length, and kind of service offered. This documentation acts as proof of the services provided and facilitates accurate billing.
- When filing claims for telehealth mental health services, include such a modifier with the relevant CPT codes. For example, if you’re paying for an individual counseling session via telehealth, apply CPT code 90801.
- Make sure you understand each insurer carrier’s telemedicine billing rules. Some payers may have their own set of guidelines for using such modifiers or submitting claims.
Benefits of 95 Modifier for Telehealth
Its utilization in telehealth services offers several important advantages to patients and healthcare professionals, including:
- To help providers get the right kind of payment from insurers, modifier 95 in medical billing ensures that telehealth services are appropriately labeled in billing.
- Patients can receive medical treatments from the convenience of their homes, eliminating the need for travel.
- Telehealth services aid providers in following federal standards and payment requirements. Maintaining correct medical records and averting future audits depends on this compliance.
- Virtual visits allow patients to keep up with routine check-ups and follow-ups with their physicians. It improves chronic condition management and promotes overall continuity of care.
- Visits conducted via telehealth may be more affordable for both patients and providers. While clinicians can see more patients without incurring the administrative costs of in-person visits, patients save time and money on travel.
Modifier 95 and POS 11
Modifier 95 in medical billing is affixed to the CPT code of service, signifying that it was delivered through a real-time, interactive audio and video telecommunication system. This modifier differentiates telehealth services from traditional in-person care, thereby assisting insurers in identifying the nature of the virtual visit. Payers must process telehealth claims effectively; however, incorrect service coding can lead to denials. Although this may seem straightforward, the complexities involved require meticulous attention. It is a single mistake that can have significant ramifications.
The POS code 11 indicates that the service was rendered in a location typically associated with the provider’s billing operations. When paired with the code, POS 11 implies that the service. However, it is delivered through telehealth and is conducted from the provider’s office. This combination is advantageous because it allows providers to secure reimbursement.
GT Modifier Vs. 95 Modifier
1.GT Modifier:
- Indicates a service provided via synchronous telecommunication.
- Commonly used in Medicaid programs and some private insurance plans.
- Helps distinguish between in-person and telehealth services for proper claims processing.
- Usage depends on state-specific telehealth policies and payer requirements.
2.Modifier 95:
It signifies that service was delivered through real-time interactive audio and video communication.
- Widely used under CPT guidelines from the American Medical Association (AMA).
- Often required by Medicare and many private insurers for telehealth billing.
- It has become more standardized with the expansion of telehealth services, offering broader recognition across various payers.
Documentation Requirements for 95 Modifier
Documentation requirements for Modifier 95 in medical billing involve capturing specific details about the telehealth encounter. So it ensures compliance and proper reimbursement. Here are the key points that should be included when documenting it:
- The documentation should specify that the interaction occurred virtually. It meets the telehealth service requirements for real-time audio and video communication.
- Include details about where the patient and the provider were located during the telehealth session. For example, indicate that the patient was at home while the provider was in their office. This helps align with payer requirements regarding the telehealth service setting.
- Note the technology used for the session, such as a secure video conferencing platform. This helps verify that the interaction met the standards for an interactive audio-video system, which is a requirement for using it.
- Document that the patient consented to receiving telehealth services.
- Clearly state that the service was provided through telehealth. This ensures that the patient understands and agrees to the nature of telehealth care.
- Record the telehealth session’s date, time, and length, as well as key findings and any treatment or recommendations provided. This supports the claim that the session was equivalent to an in-person visit in terms of service delivery.
Final Note
This modifier is important in telehealth billing because it indicates that service was delivered via real-time video and audio. When appended to a procedure code, it facilitates insurance companies in identifying the visit as a telehealth service. Thus, it ensures appropriate payment and correct application. Modifier 95 in medical billing effectively distinguishes virtual consultations from in-person appointments, which is crucial for providers to adhere to insurance regulations. This modifier is essential for ensuring providers receive accurate service compensation, especially because of the growing demand for remote healthcare options. Although it may seem minor, its impact on billing practices cannot be understated. Thus, this code is important in telehealth billing at MAVA Care medical billing company because it shows that a service was provided through real-time video and audio communication.
