Introduction
With telehealth revolutionizing healthcare in the modern age, proper billing and coding are of utmost importance. Modifier 95 in medical billing is critical for ensuring providers are reimbursed appropriately for telehealth services delivered through audio-video communication.
This guide explains what CPT Modifier 95 is, when and how it should be used, how it differs from Modifier 93, which payers accept or reject claims with Modifier 95, and the latest updates about telehealth billing with Medicare, Medicaid, and private payers.
As a healthcare professional, biller, or RCM expert, discover how to bill telehealth services the right way and prevent expensive claim denials.
What Does Modifier 95 Mean in Telehealth Billing?
Modifier 95 medical billing is used to report a healthcare service provided via real-time interactive audio and video telecommunications.
When a CPT code is billed with Modifier 95, it alerts the payer that the service was performed via telehealth — not as an in-person encounter.
Modifier 95, introduced by the American Medical Association (AMA), applies to services listed in Appendix P of the CPT manual. When applied to a CPT code, it differentiates between in-person and telehealth visits for appropriate reimbursement.
Example:
If a provider sees a patient through real-time audio-video communication for an office visit, Modifier 95 should be added to indicate that it was a telemedicine encounter instead of an in-office face-to-face visit.
When to Use Modifier 95
Use Modifier 95 when a telehealth service is provided using interactive audio and video telecommunications.
This applies to evaluation and management visits, consultations, and other outpatient services (CPT range 99201–99215) when both the provider and patient connect via an approved telecommunication platform.
Conditions for Using Modifier 95
- The telehealth visit must use audio-video technology (not audio-only).
- The CPT code must be on the telehealth-approved list in Appendix P.
- The service rendered should be equivalent in duration and quality to an in-person visit.
Example:
A provider offering a live video consultation through a secure telehealth portal should append Modifier 95.
If the service is audio-only, use Modifier 93 instead.
What Is the Significance of Modifier 95 for Proper Payment?
Modifier 95 plays a vital role in claim acceptance and payment accuracy. Without it, payers may assume the service was delivered in person and deny the claim.
Proper Use of Modifier 95 Ensures
- Compliance with telehealth billing guidelines.
- Accurate reimbursement for audio-video services.
- Clear differentiation between telehealth and office-based visits.
Incorrect use — such as failing to append Modifier 95 or mixing it with in-person POS codes — can cause denials, delayed reimbursement, and compliance risks.
Modifier 95 vs. Modifier 93: What’s the Difference?
Both modifiers apply to telehealth billing but are specific to different communication modes.
| Modifier | Use Case | Description |
|---|---|---|
| Modifier 95 | Audio-video (real-time synchronous) | For telemedicine delivered via interactive video and audio. |
| Modifier 93 | Audio-only | For telehealth delivered via telephone or audio-only platforms. |
Example:
- If a provider evaluates a patient over a video call, use Modifier 95.
- If the visit is conducted over the phone only, use Modifier 93.
Understanding this distinction prevents claim rejections and ensures billing accuracy.
Billing for Telehealth Services Using Modifier 95
Follow these steps to bill telehealth services correctly:
- Select the appropriate CPT code from the approved telehealth services list.
- Append Modifier 95 to indicate a telehealth service.
- Use the correct POS (Place of Service) code — typically POS 02 or POS 10.
Example:
- CPT code: 99213 – Office visit
- POS: 10 – Telehealth at the patient’s home
- Modifier: 95 – Real-time audio-video service
Adding Modifier 95 tells the payer that the service was rendered via real-time telecommunication and qualifies as telehealth.
Breaking Down CPT Codes and POS in Telehealth Billing
Correct telehealth billing depends on proper CPT codes and POS (Place of Service) usage.
Common CPT Codes
- 99201–99215: Office or outpatient visits
- 99441–99443: Telephone consultations
- G2012: Virtual check-ins
Common POS Codes
- POS 02: Telehealth from a distant site
- POS 10: Patient’s home (telehealth from residence)
Accurate POS and Modifier 95 application helps payers recognize and reimburse telehealth visits properly.
Modifier 95 and Medicare Telehealth Services
Key Medicare Guidelines
- Use Modifier 95 for services provided via real-time audio and video.
- Only use CPT codes listed on the Medicare Telehealth Services List.
- POS 10 – For services at a patient’s home.
- POS 02 – For services at other facilities.
Medicare continues to reimburse telehealth services under post-pandemic provisions, allowing patients to access virtual care conveniently.
Private Payers and Medicaid Guidelines for Modifier 95
While Medicare follows uniform rules, private payers and Medicaid programs may have their own telehealth billing policies.
Key Points
- Most private payers still recognize Modifier 95 for audio-video telehealth.
- Some Medicaid programs require Modifier 93 for audio-only services.
- Always verify payer-specific rules and documentation requirements before billing.
Failing to follow individual payer rules can result in denials and non-reimbursement.
Common Telehealth Billing Mistakes and Claim Denials
Even experienced billers make telehealth errors.
Here are frequent mistakes to avoid:
- Forgetting to append Modifier 95.
- Using the wrong POS code (e.g., POS 11 instead of POS 10).
- Confusing Modifier 93 with Modifier 95.
- Billing for non-approved telehealth CPT codes.
Double-checking your telehealth claims helps avoid denials and ensures fast reimbursement.
Best Practices to Stay Compliant with Telehealth Billing
Follow these steps to simplify telehealth billing and maintain compliance:
- Review payer-specific telehealth policies regularly.
- Use Modifier 95 for audio-video sessions and Modifier 93 for audio-only.
- Verify CPT and HCPCS codes with AMA and CMS sources.
- Train billing teams on POS and modifier usage.
- Record when real-time audio and video technology is used during visits.
Adopting these best practices ensures accurate billing, timely payments, and compliance with telehealth rules.
Summary: What We Learned About Modifier 95
- Modifier 95 = Telehealth via real-time audio-video.
- Modifier 93 = Telehealth via audio-only.
- POS 10 – Patient’s home; POS 02 – Other locations.
- Check payer policies for Medicare, Medicaid, and private insurers.
- Correct telehealth billing avoids denials and underpayments.
Final Word
With telehealth now a permanent part of modern medicine, understanding Modifier 95 is essential for every healthcare provider and biller.
Proper use of Modifier 95 ensures correct payment, compliance, and smooth claims processing. When applied correctly, it supports your practice’s financial health while maintaining adherence to payer and CMS
FAQs
Q1. What is Modifier 95 used for?
Modifier 95 indicates that a medical service was provided through real-time audio and video communication.
It helps insurance companies distinguish telehealth services from in-person visits, ensuring proper reimbursement.
Q2. What is the 95 Modifier Description?
The 95 modifier is defined as a code used for telemedicine services conducted via real-time audio and video systems between the healthcare provider and the patient.
Q3. What is the Reimbursement Policy for CPT Modifier 95?
Many insurance companies — including Medicare and commercial payers — reimburse telehealth services billed with CPT Modifier 95 at the same rate as in-person visits.
Q4. Is There a Requirement for Separate Documentation for Modifier 95 Claims?
Yes. The provider’s documentation must clearly specify that the encounter occurred via real-time audio and video.
It should also include patient consent and platform details if required by the payer.
Q5. How Can Pro-MedSole RCM Help with Modifier 95 Billing?
At Pro-MedSole RCM, we carefully review every telehealth claim to ensure Modifier 95 is applied correctly.
Our expert billing team verifies payer-specific requirements, checks supporting documentation, and ensures accurate CPT coding to prevent denials and secure timely payments.