Does Medicare accept the 95 modifier?

Traditional Medicare generally does not require or rely on Modifier 95 for standard professional telehealth claims, tracking the service instead through the appropriate Place of Service (POS) code.

Traditional Medicare Rules

• Place of Service Codes: For standard Part B professional claims, Medicare identifies a telehealth encounter using POS 02 (telehealth provided other than in the patient's home) or POS 10 (telehealth provided in the patient's home) rather than a separate telehealth modifier.
• Institutional Exceptions: Modifier 95 remains necessary for specific institutional or facility billing, such as outpatient therapy services provided via telehealth by hospital-employed physical, occupational, or speech-language pathologists.

Commercial Payers and Medicare Advantage

• Different Requirements: While traditional Medicare fee-for-service relies on POS codes, many commercial insurance plans, Medicaid programs, and Medicare Advantage plans still explicitly require Modifier 95 alongside the POS code for synchronous audio-video telehealth visits. Always check individual payer guidelines.

Use Modifier 93 for live, synchronous audio-only telephone telehealth encounters, and use Modifier 95 for real-time interactive audio-visual (two-way video and audio) telehealth visits.

When to Use Modifier 95 (Audio-Visual)

• Live Video: The patient and clinician interact face-to-face in real time using a two-way audio and video platform.
• Standard Telehealth: It applies to standard virtual care visits, Evaluation and Management (E/M) services, and behavioral health sessions.
• Code Lists: The CPT code must appear in AMA CPT Appendix P.
• Acceptance: It is widely accepted by Medicare and major commercial insurers when paired with a correct Place of Service (POS) code like POS 10 (patient's home) or POS 02 (location other than home).

When to Use Modifier 93 (Audio-Only)

• Phone Only: The entire live session is conducted by telephone with no video component utilized at any point.
• Technical Barriers: Used when video is unavailable, the patient lacks accessible video technology, or the patient explicitly requests/consents to an audio-only format.
• Code Lists: The CPT code must be supported by AMA CPT Appendix T.
• Payer Rules: Coverage and reimbursement vary widely by commercial insurance, state Medicaid, and specific service type; always verify that the payer permits audio-only billing before submitting. (Note: Medicare may require specific alternative codes like modifier FQ for audio-only behavioral health).

Medicare accepts hundreds of two-digit CPT and HCPCS level II modifiers to adjust pricing, specify anatomic sites, or convey billing policy requirements.

Common Medicare Modifiers

• Bilateral & Anatomy: Use RT (right) and LT (left) or 50 (bilateral procedure) to identify specific body sides.
• Distinct Services: Use 59 or subset modifiers XE, XP, XS, and XU for distinct procedural services.
• ABN & Non-Covered: Use GA (waiver on file), GY (statutorily excluded), or GZ (expected denial, no waiver).
• Drugs & Waste: Use JW (discarded drug amount) and JZ (zero discarded amount from single-dose containers).
• Therapy Plans: Use GN, GO, or GP to denote services under speech, occupational, or physical therapy plans of care.

Rules for Submission

• Order matters: Put pricing/payment modifiers first, followed by policy requirement modifiers (like KX) and informational codes last.
• Check local rules: Consult your local Medicare Administrative Contractor (MAC) for exact, up-to-date regional requirements.

Modifier 95 is not universally required for all telehealth services in 2026, because requirements depend entirely on your specific insurance payer, the place-of-service (POS) code used, and the CPT code family.

Insurance Payer Rules

• Commercial and Medicaid Plans: Most commercial insurers and Medicaid managed care programs still require Modifier 95 when billing standard evaluation and management (E/M) codes (such as 99202–99215) for live audio-video sessions.
• Traditional Medicare: Medicare relies primarily on Place of Service codes—POS 10 for home or POS 02 for locations outside the home—to designate a virtual visit rather than strictly enforcing Modifier 95 for standard professional claims. However, specific settings like hospital-employed outpatient therapy or rural health clinics (RHCs/FQHCs) have distinct updating rules detailed by the California Medical Association and CMS MLN Guidance.

Procedure Code Exceptions

• New Telehealth Codes (98000–98015): If you use the dedicated telehealth E/M code range, Modifier 95 is not required because the audio-video modality is already built into the code description.
• Audio-Only Visits: Modifier 95 is strictly for live video. Audio-only phone calls require Modifier 93 instead.

Always check your specific payer contracts and review the latest OmniMD Billing Guide to confirm local policy requirements before claim submission.

Yes, you can bill CPT code 99214 with modifier 95 when providing synchronous audio-video telehealth services for an established patient.

Key Billing Requirements

• Modality: The encounter must use real-time interactive audio and video communication. (Audio-only visits typically require modifier 93 instead, where allowed).
• Place of Service (POS): Pair the claim with POS 10 if the patient is at home, or POS 02 if the patient is at a non-home location.
• Documentation: The clinical note must support the 99214 criteria—such as moderate-to-high medical decision-making or 30–39 total minutes of time—while explicitly confirming the video technology used and session length.
• Payer Rules: Always verify specific guidelines, as commercial insurers and managed care plans have varying requirements for telehealth modifiers and coverage.