Modifier 95

Modifier 95 marks a visit as telehealth. Appended to the procedure code, it tells the payer the provider and patient were connected by live two-way video rather than in the same room. Payers use that flag to apply their telehealth coverage rules: whether the code is payable by video at all, what rate applies, and whether a facility fee or originating site rule comes into play. Audio-only visits are a different thing, and payers that cover them generally want a different modifier, so the note has to say which it was.

Where it gets confusing is that payers do not agree on how telehealth should be flagged. Some want modifier 95 on every telehealth line regardless of place of service; others key everything off the place of service code and ignore the modifier. For Medicare professional claims, CMS’s telehealth booklet points to POS 02 (patient not at home) and POS 10 (patient at home) as of January 1, 2024, and names modifier 95 specifically for outpatient therapy furnished via telehealth by hospital-employed therapists on institutional claims. Medicaid programs and commercial plans publish their own telehealth billing guides, and the combination that works for one plan can deny at the next.

The mistake is a single telehealth template. A practice sets up one rule, say POS 02 plus 95, and applies it to every payer. Build the telehealth setup payer by payer from each payer’s current policy, review it when the policy changes, and make sure the note records the patient’s location and the technology used, because that is what an auditor checks against the codes.