The 95 modifier is a new coding modifier used for claims. It was introduced in 2017 and is different from CPT or procedure codes, and describes the claim.
One example of a modifier that has been used for many years is the HJ modifier which is used to code EAP claims.
95 Modifier Description
The 95 modifier is defined as “synchronous telemedicine service rendered via a real-time audio and video telecommunications system.”
In other words, this is a way to describe a Telehealth session. Historically, Telehealth coverage varies significantly by insurer.
A service like TheraThink can call ahead to make sure it is covered and being properly billed.
Another aspect to note, is that this must include video so it does not apply to phone therapy sessions.
2020 Telehealth Standards
With the onset of coronavirus in 2020, the coding standards for Telehealth have been changing and getting updated faster than ever.
Medical billing is normally a slowly changing elephant, but basically overnight the industry is scrambling with varying standards.
This is mostly good news as Telehealth is being covered more than ever but the 2020 Telehealth coding standards are incredibly dynamic and are very confusing to figure out.
What CPT Code Do I Use With the 95 Modifier?
This is billed with standard mental health CPT codes like 90791, 90834, or 90837.
Place of Service Code. 02 or 11?
Non-telehealth visits are coded with a place of service 11 to indicate an office. There has been significant back and forth between coding Telehealth visits with 11 and 02 (the place of service code for Telehealth).
This is another area where we recommend contacting or researching ahead of time before filing a claim. The standard is generally 02 but varies depending on the insurer and plan.
95 Modifier vs. GT Modifier
A GT modifier is an older coding modifier that serves a similar purpose as the 95 modifier. CMS recommends 95, different companies have varying standards for which codes to be billed.
It is a good idea to check with the plans before billing. A billing specialist like TheraThink can help to ensure this is done correctly.
GT Modifier Reimbursement
Many providers are concerned that Telehealth visits may reimburse less. However, because the procedure codes are the same, the fee schedule reimbursement should remain the same.
How Do I Bill the 95 Modifier on a CMS 1500 Form?
Like other coding modifiers, the 95 modifier should be used under the 24d field on the CMS 1500, with the CPT code in 24c.