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Billing Modifiers

Modifier 95: Telehealth E/M Service

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

Telehealth policies change often, and modifier 95 claims deny when a payer updates them. Checks the 95 and the place of service on the claim against that payer's current policy before it goes out.

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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