Understanding Modifier 95: A Brief Overview
Modifier 95 is a medical billing code used to indicate that a service was provided via telehealth. This modifier is essential for ensuring that healthcare providers receive appropriate reimbursement for remote services.
Here are the key points about Modifier 95:
- Purpose: Modifier 95 is appended to the CPT or HCPCS code for a service that was 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 but are provided remotely, 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.
Key Situations for Using Modifier 95
- Telehealth Visits:
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- Initial consultations: When a patient is seen for the first time using telehealth technology.
- Follow-up visits: Subsequent visits with a healthcare provider via telehealth.
- Established patient visits: When the patient has been seen within the past 3 years.
- New patient visits: When the patient is new to the practice and is seen via telehealth.
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- 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.
Master Telehealth Billing: Essential Steps and Allzon’s Support
Key Steps to Effective Telehealth Billing:
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- Stay Updated: Keep abreast of changes in telehealth regulations, payer policies, and coding guidelines.
- Train Staff: Ensure that billing staff is well-versed in the proper use of Modifier 95 and understands the specific requirements for telehealth billing.
- Verify Eligibility: Before providing telehealth services, verify the patient’s insurance eligibility and coverage for telehealth services.
- Maintain Accurate Records: Keep detailed records of telehealth visits, including patient consent, service provided, and any supporting documentation.
- Review Claims: Regularly review submitted claims to identify any errors or discrepancies related to telehealth billing.
How Allzon Can Help Your Medical Billing Company:
Allzon Management Services can provide comprehensive support to medical billing companies, helping them stay compliant, optimize revenue, and minimize claim denials. Our expert team can assist with:
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- Regulatory Compliance: Ensuring adherence to all relevant telehealth regulations and guidelines.
- Staff Training: Providing training and resources on telehealth billing best practices.
- Eligibility Verification: Streamlining the eligibility verification process.
- Documentation Management: Assisting with the creation and maintenance of accurate medical records.
- Claim Review and Appeals: Identifying and addressing claim errors, and managing appeals.
By partnering with Allzon Management Services, medical billing companies can enhance their telehealth billing operations and achieve optimal financial performance.