Modifier 95

When is modifier 95 used?

Modifier 95 is a coding modifier used to indicate that a service was provided via synchronous telecommunication, such as real-time audio and video interaction, by a healthcare provider. This modifier is specifically used for telehealth services to distinguish them from in-person services. It helps ensure accurate billing and reimbursement for telehealth visits, which have become increasingly prevalent in healthcare delivery.

By using Modifier 95 appropriately, healthcare providers can account for the unique considerations of telehealth services, such as the lack of physical proximity between provider and patient. This coding modifier plays a crucial role in accurately documenting and tracking telehealth services, which are vital for both patient care and financial operations in healthcare settings.

This modifier should be appended to codes marked with a star symbol when electronic communication is conducted via such a system. The utilization of Modifier 95 allows healthcare providers to accurately indicate when telemedicine services were provided in real time, ensuring proper coding and reimbursement for these services.

When applying Modifier 95, it is crucial to reference appendix P, which provides a list of codes that are eligible for this modifier. By consulting this appendix, healthcare professionals can verify which specific services qualify for synchronous telemedicine billing using Modifier 95.

Examples of modifier 95

Here are some examples of scenarios where Modifier 95 would be appropriately applied:

1. A patient presents with a concerning rash and schedules a telemedicine appointment with their dermatologist. The dermatologist conducts a real-time video consultation with the patient to visually assess the rash, provide a diagnosis, and prescribe treatment. In this scenario, Modifier 95 would be appended to the appropriate evaluation and management (E/M) code.

2. A primary care physician conducts a follow-up appointment with a patient who is managing a chronic illness such as diabetes. During the telemedicine visit, the physician reviews the patient’s blood glucose readings, adjusts their medication regimen, and provides counseling on lifestyle modifications. Modifier 95 would be added to the applicable E/M code for this encounter.

3. A mental health provider conducts a therapy session with a patient via a secure telemedicine platform. The session involves real-time audio and video communication to provide counseling and support for the patient’s mental health concerns. Modifier 95 would be applied to the relevant psychotherapy code to indicate the use of synchronous telemedicine services.

4. A patient in a rural area seeks medical advice from a specialist located in a different city. The specialist conducts a live video consultation with the patient to assess their condition, provide recommendations, and discuss treatment options. In this case, Modifier 95 would be added to the appropriate CPT code to indicate that the service was provided via telemedicine.

5. A psychiatrist remotely evaluates a new patient with a history of anxiety disorders. The psychiatrist conducts a real-time video session with the patient to conduct a comprehensive psychiatric evaluation, provide a diagnosis, and establish a treatment plan. Modifier 95 would be appended to the CPT code for the evaluation to denote that the service was delivered through telemedicine.

6. A primary care physician follows up with a patient who recently underwent surgery. The physician uses a secure telemedicine platform to conduct a live video visit with the patient, review post-operative recovery progress, address any concerns, and provide further guidance. Modifier 95 would be applied to the relevant CPT code to indicate that the visit was conducted synchronously via telemedicine.