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Modifier 95

Definition

Modifier 95 is used to indicate an evaluation and management service delivered via real-time, synchronous telehealth using interactive audio and video technology. The patient and provider must be in two-way visual and audio communication during the visit. Modifier 95 is appended to the standard E/M code and reimburses at the same rate as in-person E/M.

When to Use

  1. Follow-up visit for established patient via video conference (99214-95 for office visit via telehealth)
  2. New patient comprehensive visit via Zoom or similar HIPAA-compliant platform (99203-95)
  3. Psychiatric medication management via telehealth (99213-95)
  4. Preventive care annual exam via telehealth for established patient (99397-95 for established patient periodic visit)

Documentation Requirements

Document that service was delivered via real-time telehealth with video and audio capability. Note patient location and provider location. Confirm patient consent to telehealth. Document technology used (Zoom, Webex, etc. if HIPAA-compliant). Note any technical difficulties. Standard E/M documentation (HPI, ROS, PFSH, assessment, plan) applies. Time-based billing requires actual visit time documented.

Payer-Specific Rules

Payer Acceptance Common Denials Notes
Medicare Accepted; full reimbursement CO-59: Service not separately payable Allows modifier 95. No geographic restrictions post-emergency period. Require video visit doc.
Aetna Accepted; full reimbursement CO-8: Service denied based on plan Covers 95 same as in-person. May require in-network telehealth platform.
United Healthcare Accepted with limitations CO-4: Service bundled Full coverage. Some plans restrict to established patients only.
Cigna Accepted; full reimbursement CO-3: Service not covered Allow 95 visits. May require pre-authorization for new patients.
Humana Accepted; full reimbursement CO-16: Service not medically necessary Cover modifier 95. Deny if visit not medically necessary (preventive may have limits).
  • 96 – Asynchronous digital E/M service. Use when using store-and-forward technology, not real-time video.
  • 25 – Significant E/M. Use if separate E/M provided with procedure same day.
  • PQ – Telehealth by rural health clinic. Use if service in rural federally qualified health center.
  • GT – Via interactive audio/video. Older modifier; 95 preferred post-2021.

Common Denials

CARC Code Reason Primary Cause
CO-59 Service not separately payable Claim shows both in-person and telehealth visit same day without proper modifier.
CO-151 Documentation missing Claim lacks evidence video/audio connection occurred.
CO-16 Service not medically necessary Payer deems preventive telehealth visit not covered under plan.

FAQ

Can I bill modifier 95 for a phone-only visit?

No. Modifier 95 requires real-time video and audio. Phone-only visits are not billable as E/M with 95.

Do I need to bill modifier 95 with modifier 25 on same day as procedure?

Yes. If procedure done same day as E/M telehealth, use both: 99213-25-95.

Is modifier 95 reimbursed at the same rate as in-person E/M?

Yes, Medicare and most payers pay modifier 95 at 100% of in-person E/M rates.

Prevent These Denials

Altair's co-pilot checks telehealth modifier requirements and flags documentation gaps before you submit.

Related Resources

This reference is current as of 2026-03-23. Payer policies change. Always verify against the payer's latest policy documentation.
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