Modifier 95: A Comprehensive Guide to Telehealth Billing

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

1. Telehealth Visits:
   • • 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.
2. Telehealth Consultations:
   • When a healthcare provider consults with another provider about a patient using telehealth.
3. 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.

Master Telehealth Billing: Essential Steps and Allzon’s Support

Key Steps to Effective Telehealth Billing:

• • 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:

• • 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.

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.