Telehealth services use modifier 95 for real-time, synchronous video and audio visits, and modifier 96 for asynchronous store-and-forward services. Both modifiers are appended to E/M codes and reimburse at the same rate as in-person visits. The key distinction: modifier 95 requires live two-way communication; modifier 96 involves delayed response to patient-submitted information.
Modifier 95 is used for real-time, interactive telehealth visits via video conference (Zoom, WebEx, Skype) with two-way audio and video capability. Patient and provider must be in simultaneous communication. Visit can be established patient follow-up, new patient comprehensive, psychiatric medication management, or preventive visit. Medicare and most payers reimburse 95 at 100% of in-person E/M rates. Document visit was via video with audio/video capability, patient location, provider location, and HIPAA-compliant platform used.
Modifier 96 is for store-and-forward technology: patient submits images, video, lab results; provider reviews and responds within agreed timeframe (not real-time). Examples: patient photos for skin condition review, patient video message, electronic health record questionnaire response. Reimbursement: typically 50-75% of in-person E/M rates (varies by payer). Medicare covers limited asynchronous services (usually 99450-99452 for established patients). Requires documented response timeframe and total time spent reviewing and responding.
Modifier 95: Standard E/M documentation (HPI, ROS, PFSH, examination, assessment, plan). Time-based billing requires actual visit time documented. Note visit was via telehealth with video/audio. Modifier 96: Document patient submitted materials date and content type, provider review date and time spent, provider response/assessment/plan date and time. Total time spent includes review and response time, not patient wait time.
Medicare: Both 95 and 96 reimbursed; 95 at 100% of in-person rate (no geographic restrictions post-2021), 96 at 100% for established patients (limited codes). Aetna: Both accepted at 100% in-person rates. United Healthcare: 95 full coverage; 96 limited to selected codes. Cigna: 95 covered; 96 requires pre-authorization. Humana: 95 and 96 both covered with similar rates to in-person.
Billing 95 for phone-only call (requires video). To avoid: ensure HIPAA-compliant video platform used. CO-151: Documentation missing. Document visit method explicitly. CO-59: Same visit billed twice (in-person and telehealth). To avoid: bill only one visit mode per day. CO-16: Service not medically necessary. Justifiable for follow-up visits; preventive may have restrictions on some plans. CO-4: Service bundled. Asynchronous services may bundle differently; review payer rules for 96 codes.
No. Modifier 95 requires interactive video and audio. Phone-only is not billable as E/M with 95. Patient must have video capability.
Modifier 95: Yes, Medicare and most payers pay 100% of in-person E/M rate. Modifier 96: Usually 50-75% of in-person E/M, varies by payer.
Typically no. If you have one synchronous visit (95), do not bill asynchronous service (96) same day. Each day should be one visit mode or clearly separate encounters.
Altair's co-pilot verifies telehealth visit documentation and modifier compliance before claims go out.