Is modifier 95 still used?

Yes, modifier 95 is still actively used in medical billing to designate synchronous, real-time interactive audio-video telehealth services.

Current Usage Rules

• Synchronous Audio-Video: Append modifier 95 to eligible CPT codes (such as those in Appendix P of the CPT manual) when a virtual visit utilizes both live audio and live video.
• Commercial vs. Medicare Rules: Many commercial insurers still require modifier 95 to explicitly flag standard professional or E/M codes as telehealth. However, for standard Medicare professional claims, Medicare relies primarily on Place of Service (POS) codes—POS 02 (telehealth other than in a patient's home) and POS 10 (telehealth in the patient's home)—rather than automatically requiring modifier 95, though specific institutional or state program exceptions apply.
• Exclusions: Do not use modifier 95 for audio-only calls (which use modifier 93) or asynchronous/store-and-forward services (which use modifier GQ).

Yes, you can bill CPT code 99214 with modifier 95 when providing synchronous audio-video telemedicine.

Key Billing Requirements

• Modality: The visit must use real-time audio and video communication.
• Place of Service (POS): Match the claim with the correct location code. Use POS 10 if the patient is at home, or POS 02 if the patient is at a location other than home.
• Documentation: The clinical note must support moderate medical decision-making (MDM) or 30 to 39 total minutes of time, plus confirm the live audio-video technology used.
• Payer Rules: Verify if your specific commercial or managed care payer requires modifier 95, as rules vary by contract.

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.

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).