Medical RAC Audits Reviewed by Statistician Frank Cohen Medical RAC Audits Reviewed by Statistician Frank Cohen

New In 2017: Modifier 95 And Telemedicine Codes

There’s a new modifier for telehealth services rendered to patients who are on private insurance rather than Medicare. Modifier 95 (synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system) can be appended to E/M visit codes (99201-99205 for new patients, 99211-99215 for established patients).

This change doesn’t affect Medicare, which will still rely on the existing modifier GT (services delivered via interactive video and video telecommunication systems). The biggest obstacle from a Medicare standpoint continues to be the issue of the “originating site,” which is the physical location of the patient.

Telehealth would be a game-changer if the originating site could be a patient’s home; instead CMS continues to require that the originating site be outside of major metropolitan areas (as defined by metropolitan statistical areas or MSAs). The agency provides an online tool to determine whether an office or hospital location qualifies as an originating site for telehealth.

CMS pays a facility fee to the facility or office serving as the originating site (reported using the HCPCS code Q3014), and professional fee based on the CPT code supported to the provider who renders the E/M service. That E/M code receives either modifier GT or 95 depending on payer.

Another change for 2017 is the new place of service (POS) code created specifically to represent telehealth. The new code is 02 and defined as “Telehealth: the location where health services and health-related services are provided or received, through telehealth telecommunication technology.”

Private payers ahead of the curve

Fortunately, private insurance companies tend to be more progressive than CMS in paying for telemedicine. Many, though not all, private payers allow the originating site to be a patient’s home. Part of the reason are telemedicine “parity” laws passed in many states require payers operating in their jurisdiction to reimburse telemedicine E/M services the same way they would in-person services.

The list of states with such a law is below:

  • Arizona
  • Arkansas
  • California
  • Colorado
  • Delaware
  • Georgia
  • Indiana
  • Kentucky
  • Louisiana
  • Maine
  • Maryland
  • Michigan
  • Minnesota
  • Mississippi
  • Missouri
  • Montana
  • Nevada
  • New Hampshire
  • New Mexico
  • New York
  • Oregon
  • Oklahoma
  • Tennessee
  • Texas
  • Vermont
  • Washington state
  • Washington, D.C.

Several other states have parity bills in the process of being signed. The American Telemedicine Association (ATA) maintains trackers on its website. Coverage will vary based on payer, though all payers in the listed states above must reimburse telemedicine for patients whose plans cover the service. You will also need to check that the payer doesn’t follow Medicare’s highly restrictive “originating site” definition. Be sure to utilize modifier 95 properly in these cases.