Telehealth has revolutionized healthcare delivery, offering unprecedented access to care and convenience for patients. However, navigating the complexities of telehealth billing, particularly the proper use of telehealth modifiers, remains a significant challenge for many healthcare providers. Accurate modifier application is crucial for timely reimbursement and avoiding claim denials. This comprehensive guide aims to understand telehealth modifiers, providing essential, technical, and payer-specific insights to ensure your practice remains compliant and financially healthy.
What Are Telehealth Modifiers and Why Are They Crucial?
Telehealth modifiers are two-character codes appended to CPT® or HCPCS codes on claims to indicate that a service was delivered via telehealth. They signal to payers the method of delivery, the patient’s location, and other pertinent details that differentiate a virtual visit from an in-person encounter. Without the correct modifiers, your telehealth claims are highly susceptible to rejections, leading to revenue cycle disruptions and administrative burdens.
Understanding Key Telehealth Modifiers
While telehealth billing guidelines can be dynamic, several modifiers are commonly used. Understanding their specific applications is paramount.
1. Modifier 95: Synchronous Telemedicine Service
- Definition: This is the most widely recognized modifier for synchronous (real-time, interactive) telemedicine services. It signifies that the service was rendered via a real-time interactive audio and video telecommunications system.
- Application: Modifier 95 is appended to the CPT® code for the service provided (e.g., a telehealth evaluation and management (E/M) visit, psychotherapy session). It generally applies to services that could otherwise be provided in person but were delivered virtually.
- Payer Considerations: Most commercial payers and Medicare use Modifier 95 for audio-video telehealth. It’s crucial to confirm if the specific CPT code is eligible for telehealth and if the payer accepts Modifier 95 for that service.
2. Modifier 93: Audio-Only Telehealth Service
- Definition: This modifier indicates a “synchronous telemedicine service rendered via telephone or other real-time interactive audio-only telecommunications system.”
- Application: Modifier 93 is used when a telehealth service is provided solely through audio, without a video component. This is often applicable when a patient lacks the technical capacity or does not consent to video use, or for specific behavioral health services where audio-only is permitted.
- Payer Considerations: While initially expanded during the Public Health Emergency (PHE), Medicare has permanently allowed audio-only for mental health services delivered to patients in their homes. For non-behavioral/mental telehealth, audio-only is generally permitted through September 30, 2025, if the patient is in their home and unable or unwilling to use video. Commercial and Medicaid policies vary significantly, so always verify coverage for audio-only services.
3. Modifier GT: Interactive Audio and Video Telecommunication Systems (Older/Limited Use)
- Definition: Historically, Modifier GT was used for telehealth services rendered via interactive audio and video telecommunication systems.
- Application: While still used by some payers, Modifier 95 has largely replaced GT for most synchronous telehealth services. Medicare, for instance, generally does not require a GT modifier for audio-video telehealth services, relying instead on the Place of Service (POS) code.
- Payer Considerations: It’s essential to check individual payer guidelines. For example, some institutional claims billed by Critical Access Hospital (CAH) Method II providers might still use GT.
4. Modifier FQ: Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) Audio-Only
- Definition: This modifier specifically applies to audio-only services furnished by FQHCs and RHCs.
- Application: FQHCs and RHCs may use Modifier FQ (and/or 93 where appropriate) for eligible audio-only behavioral health services.
- Payer Considerations: This modifier is typically tied to specific payment methodologies for FQHCs and RHCs and their extended flexibilities.
Place of Service (POS) Codes: The Critical Companion to Telehealth Modifiers
In addition to modifiers, the correct Place of Service (POS) code is fundamental for accurate telehealth billing. The POS code indicates where the service was rendered. For telehealth, two specific POS codes are crucial:
1. POS 02: Telehealth Provided Other than in the Patient’s Home
- Definition: Used when the telehealth service is delivered via telecommunications, and the patient is not located in their home (e.g., in a facility, another medical office).
- Impact on Reimbursement: As of January 1, 2024, Medicare pays services billed with POS 02 at the facility rate.
2. POS 10: Telehealth Provided in Patient’s Home
- Definition: Used when the telehealth service is delivered via telecommunications, and the patient is located in their home (a private residence).
- Impact on Reimbursement: As of January 1, 2024, Medicare pays services billed with POS 10 at the non-facility rate, which is generally higher to account for practice overhead.
Do not use POS 11 (Office) for telehealth services. It is an inappropriate POS for virtual care and will likely lead to denials
Payer-Specific Billing Considerations and Recent Updates (2024-2025)
The landscape of telehealth reimbursement is constantly evolving. Staying updated on payer-specific policies and recent regulatory changes is crucial.
Medicare
- Flexibilities Extended: Many COVID-19 PHE telehealth flexibilities have been extended through September 30, 2025. This includes allowing patients to receive non-behavioral/mental health telehealth services in their home, waiving geographic restrictions, and allowing all eligible Medicare providers to furnish telehealth.
- Audio-Only: Permanent allowance for behavioral/mental health services delivered to patients in their home via audio-only. For non-behavioral/mental telehealth, audio-only is allowed through September 30, 2025, if the patient is in their home and cannot or will not use video.
- Direct Supervision: Virtual direct supervision (real-time audio and visual) is permitted through December 31, 2025.
- No Modifier for Audio-Video: Medicare does not require a modifier for audio-video telehealth services when billed with POS 02 or POS 10. Modifier 93 is used for audio-only services.
Medicaid
- State-Specific: Medicaid telehealth policies are determined at the state level and can vary significantly regarding covered services, eligible modalities (audio-only vs. audio-video), modifiers, and originating/distant site requirements.
- Managed Care Organizations (MCOs): If you contract with Medicaid MCOs, always consult their specific provider manuals or policies, as they may have unique billing guidelines.
Commercial Insurers
- Payer-Specific Policies: Commercial, self-funded, and Medicare Advantage policies vary widely. Always check with each individual payer for their most recent telehealth policies, including:
- Which CPT codes are covered via telehealth?
- Required modifiers (e.g., some may prefer or require Modifier 95, others may have specific proprietary modifiers).
- Acceptable POS codes.
- Coverage for audio-only services.
- Prior authorization requirements.
- Reimbursement rates.
Common Telehealth Billing Pitfalls to Avoid
Even with the correct modifiers and POS codes, billing errors can lead to denials. Watch out for these common issues:
- Incorrect CPT Code Selection: Ensure the CPT code accurately reflects the service provided and is eligible for telehealth. New CPT codes for audio-video (98000-98007) and audio-only (98008-98015) telemedicine visits have been introduced in 2025, replacing some older telephone-only codes.
- Missing or Incomplete Documentation: Comprehensive documentation is critical. Include:
- Date and time of service.
- Modality of communication (audio-video, audio-only).
- Patient’s physical location.
- Provider’s location.
- Clinical justification for virtual care.
- Verification of patient identity and consent.
- Any technical issues encountered.
- Lack of Prior Authorization: Some telehealth services, particularly for specialty consultations or certain behavioral health treatments, may still require prior authorization. Always verify with the payer.
- Non-Compliance with Technology Standards: Ensure the telehealth platform used is HIPAA-compliant and meets any payer-specific technical requirements.
- Inconsistent Application of Rules: Train your billing staff thoroughly on the nuances of telehealth billing across different payers to maintain consistency and accuracy.
Conclusion
Mastering telehealth modifiers and associated billing guidelines is no longer optional; it’s a fundamental requirement. By accurately applying the correct modifiers (such as 95 and 93), utilizing appropriate Place of Service codes (02 and 10), staying abreast of payer-specific policies, and maintaining meticulous documentation, your practice can streamline its revenue cycle, minimize claim denials, and continue to provide accessible, high-quality care to patients. Regular checks of payer websites, CMS updates, and industry resources will be your best allies in this dynamic billing environment.
About Medisys
At Medisys, we understand the complexities of medical billing and coding, especially in the ever-evolving landscape of telehealth. As a leading medical billing company, we specialize in providing accurate, compliant, and specialty-specific billing services to healthcare providers. Our team stays on top of the latest payer guidelines and regulatory changes, ensuring your telehealth claims are processed efficiently, maximizing your reimbursement and minimizing administrative burden. Partner with Medisys to optimize your revenue cycle and focus on patient care.
Disclaimer:
CPT® codes, descriptions, and materials are copyrighted by the American Medical Association (AMA).
This article is intended for informational purposes only and does not constitute professional medical, legal, or billing advice. While we strive for accuracy, healthcare regulations and payer policies are subject to frequent change. Providers should always consult official payer guidelines, Medicare (CMS), Medicaid (state-specific), and commercial insurer manuals for the most current and authoritative information.
