Using Modifier 95 for Telehealth Makes Cents

Using Modifier 95 for Telehealth Makes Cents

Capture full payment for remote visits during the PHE for COVID-19.

An interim final rule published in the April 6, 2020, Federal Register explains how to bill telehealth services during the COVID-19 public health emergency (PHE). The final rule goes into great detail, explaining why the place of service (POS) code 02 is not being used for the PHE telehealth services and why the modifier 95 is needed.

Here is an explanation of the POS codes, how they tie into the Medicare fee schedule, the changes implemented during the PHE, and why they were implemented.

How POS Codes Affect Payment

CMS created the POS 02 for telehealth so that a modifier was not needed. By using POS 02, the MAC knows the service is telehealth and processes the claim as such.

For traditional telehealth (not during the COVID-19 PHE), the patient cannot be at home. They have to be at an “originating site” for the encounter. And the “originating site” bills a G code for the telehealth facility fee at the originating site. And the POS 02 pays the practice providing telehealth the “facility fee.” Each telehealth code has a facility fee and a non-facility, or office, fee. The difference between a facility fee and a non-facility (office) fee is that the facility fee does not pay the provider for practice expense. So the facility fee is less than the non-facility fee (office fee). The originating site is paid a fee for use of the facility, which makes up for taking the practice expense from the provider. POS 02, 22, 23, 24 all pay facility fees to the provider and the provider is not paid for practice expense. Whereas POS 11, office, pays the non-facility fee to the provider, which includes the practice expense.

When to Use Modifier 95

Now let’s talk about telehealth under the COVID-19 PHE. The patient does not have to go to an originating site and can take part in telehealth from their home. As a result, CMS does not have to pay a facility fee to an originating site. The provider is incurring practice expenses in delivering the telehealth, so CMS is paying providers for practice expense in the fee schedule when a provider, who usually practices in an office, provides telehealth services during the COVID-19 PHE.

If POS 02 is used, the provider will not be paid for practice expense because the POS 02 triggers the facility provider fee schedule. CMS says in the April 6 IFC that providers who usually provide services in the office should use POS 11 for their telehealth services during the COVID-19 PHE. But the MAC needs to know that the service is telehealth. Without using POS 02 and using POS 11, however, the MAC cannot distinguish between an in-person service and a telehealth encounter. That is why CMS has indicated that modifier 95 has to be added to the CPT/HCPCS Level II codes provided during the telehealth encounter. This will ensure the office, non-facility provider fee schedule will be paid, including the practice expense, and the MAC will know that the services were provided via telehealth.

Telehealth Costs Add Up

Below shows the difference in the Medicare fees with no geographic adjustment associated with facility and non-facility:

CPT® Code Facility Fee

(POS 02, 19, 21, 22, 23, 24)

Non-Facility Fee (Office)

(POS 11)

99201 $27.07 $46.56
99202 $51.61 $77.23
99203 $77.23 $109.35
99204 $132.09 $167.09
99205 $172.51 $211.12
99211 $9.38 $23.46
99212 $26.35 $46.19
99213 $52.33 $76.15
99214 $80.48 $110.43
99215 $113.68 $148.33

As you can see, reporting the proper POS and modifier on telehealth claims during the PHE for COVID-19 adds up.

Source: https://www.cms.gov/files/document/covid-final-ifc.pdf

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Barbara Cobuzzi

About Has 105 Posts

Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, AAPC Fellow, is a consultant with CRN Healthcare Solutions in Tinton Falls, N.J. She is consulting editor for Otolaryngology Coding Alert and has spoken, taught, and consulted widely on coding, reimbursement, compliance, and healthcare-related topics nationally. Barbara also provides litigation support as an expert witness for providers and payers. Cobuzzi is a member of the Monmouth, N.J., AAPC local chapter.

10 Responses to “Using Modifier 95 for Telehealth Makes Cents”

  1. Crystal says:

    Can you bill for telehealth for HB services?

  2. Christine Roskam, CPC says:

    WARNING: Conflicting (or missing) information seems to happen on a regular basis with Knowledge Center posts (which I find very dismaying). Perhaps there are regional discrepancies not being identified when articles lay out instructions as if the whole country should follow same rules? Best practice is to do your own research to ensure compliance with any given insurance!

    This article adds to the daily confusion that the PHE causes me (coding for a Family Physician in Oregon). Your instructions conflict with what I learned from the Noridian JF webinar I attended on 04/09/2020. They say (for Medicare claims) POS 02 must be used on all actual telehealth visits, and with modifier 95 on the CPT code! They also instructed to use 99441-99443 or 99421-99423 time-based codes for AUDIO ONLY visits by phone, with POS 11 and modifier GT.

    Each commercial insurance seems to have their own twist:
    Atrio/Aetna: same as CMS
    Cigna: treats “audio only” telephone encounters the same as full synchronous voice and picture, with POS 11 and GT or 95 modifier.
    Regence BCBS: same CPT coding rules as CMS, with POS 11 and modifier GT on synchronous audio/visual telehealth AND audio-only phone CPTs.
    Regence BCBS FEP: requires POS 02 and modifier 95 on all synchronous audio/visual telehealth and POS 02 with GT on audio only phone encounters.
    There are more (regional) insurances with their own slightly different rules. Some have different rules for their commercial and MedAdvantage plans.
    GEHA has no policy and I have had to assume they are following CMS’s lead.

  3. Renee Dustman says:

    Thanks, Christine. Our articles always defer to general CMS guidance. We recommend coders confirm payer policy as they often differ greatly.

  4. Renee Dustman says:

    “Can you bill for telehealth for HB services?”

    Crystal. I don’t know what you mean by “HB” services but it will depend on who’s performing the service and who the payer is. If it’s Medicare, check CMS’ telehealth code list (https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes) to see if the code is on the list and then follow CMS guidelines in place during the public health emergency for COVID-19 (https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/Current-Emergencies-page).

  5. Ariel costa says:

    I am a billing manager for a Physical Therapy office in northern New Jersey, I was wondering if it has been approved for our field? If so, for both CMS and commercial insurances?

  6. Renee Dustman says:

    This guidance is for Medicare, which is national. Commercial payers may vary; you will need to refer to their specific guidance, which is probably posted on their website.

  7. Shannon B says:

    Has anyone seen any clarification on the newest release, that states:
    “CMS previously announced that Medicare would pay for certain services conducted by audio-only telephone between beneficiaries and their doctors and other clinicians. Now, CMS is broadening that list to include many behavioral health and patient education services. CMS is also increasing payments for these telephone visits to match payments for similar office and outpatient visits. This would increase payments for these services from a range of about $14-$41 to about $46-$110. The payments are retroactive to March 1, 2020.”

    Here is the link to the actual release:
    https://www.cms.gov/newsroom/press-releases/trump-administration-issues-second-round-sweeping-changes-support-us-healthcare-system-during-covid
    Are they referring to codes 99441-99443, and if so, where are the details on coding and reimbursement for these codes now?

  8. Renee Dustman says:

    Shannon B:

    Yes they are referring to 99441-99443. These codes have been added to the Medicare telehealth code list, which also indicates the services may be conducted using audio-only communications. Aside from that, follow usual coding guidance.

  9. Frederic Glatter, M.D. says:

    Can our office resubmit claims to medicare, updating the POS to 11 and using the -95 modifier, that were originally submitted with the “02” POS and paid at the facility rate?

  10. Renee Dustman says:

    yes, as long as the dates of service were March 1, 2020 or later.

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