95 Modifier Usage

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 modifier95 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.

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