Telehealth Modifier 93 vs 95: What BH Practices Get Wrong

The pattern we are seeing across roughly 50 behavioral health practices right now is consistent: billers who treat modifier 93 and modifier 95 as interchangeable are generating denial rates between 18% and 31% on their telehealth claims. That is not a payer problem. That is a documentation and modifier-selection problem, and it is costing a mid-sized outpatient BH group with 10 licensed clinicians somewhere between $80,000 and $140,000 in delayed or written-off revenue annually.

Both modifiers describe telehealth encounters, but they describe fundamentally different technology configurations. Using the wrong one does not just trigger a denial today. It creates an audit trail that gives commercial payers a retroactive recoupment argument. This post breaks down the operational distinction, shows you where the real exposure lives in behavioral health and SUD settings, and gives you a checklist your billing team can use before the next claim drops.

The Core Distinction: Audio-Video vs. Audio-Only

Modifier 95 applies to synchronous telehealth services delivered via two-way, real-time audio and video communication. This is the standard video visit. The patient is on a HIPAA-compliant platform, both parties can see and hear each other, and the service is functionally equivalent to an in-person encounter from a clinical standpoint.

Modifier 93 was permanently adopted by CMS after the COVID public health emergency and applies to synchronous telehealth services delivered via audio-only telephone when the patient does not have access to or cannot use video technology. This is not a workaround. It is a recognized service type with specific coverage rules.

The critical operational point: modifier 93 is not appropriate simply because a patient prefers phone. The medical record must document that video was unavailable or not feasible for that specific patient on that specific date. Payers including Aetna, UnitedHealthcare, and most Medicaid managed care organizations are now running automated edits that flag claims with modifier 93 attached to providers whose practice patterns show high video-capable patient populations. If 80% of your patients use video and suddenly 40% of your claims carry modifier 93, expect a probe audit.

Place of Service Codes: Where Most Groups Make the First Mistake

Place of service coding is where the modifier confusion compounds into a real dollar problem. Here is what we are seeing in practice:

• POS 02 (Telehealth Provided Other than in Patient’s Home) applies when the patient is located at a facility or clinical site during the telehealth encounter.
• POS 10 (Telehealth Provided in Patient’s Home) applies when the patient is in their residence. For most outpatient behavioral health and SUD telehealth encounters since 2022, this is the correct code.
• Modifier 95 pairs with both POS 02 and POS 10 depending on the patient’s location.
• Modifier 93 pairs almost exclusively with POS 10 or POS 02 depending on your payer contract, but the documentation burden for 93 is higher regardless of site.

The billing failure we see most often is practices that transitioned from COVID-era POS 02 to POS 10 for home-based telehealth but never updated their modifier logic in their practice management system. Claims go out with POS 10 and modifier 95, which is correct, or POS 02 and modifier 95, which may also be correct, but when modifier 93 appears with POS 02 on a claim for a patient documented as calling from home, the payer’s system generates a mismatch denial immediately.

High-Volume BH CPT Codes and Their Telehealth Modifier Risk

Not every CPT code is eligible for modifier 93. This matters for behavioral health practices because the codes that drive most of your revenue are the same ones with the most complex telehealth coverage rules.

• 90837 (Individual psychotherapy, 60 min): Eligible for both 95 and 93 under Medicare and most commercial plans, but 93 requires explicit documentation of audio-only necessity.
• 90834 (Individual psychotherapy, 45 min): Same eligibility rules as 90837.
• 90847 (Family psychotherapy with patient): Eligible for modifier 95; modifier 93 coverage varies significantly by payer. Many commercial plans specifically exclude audio-only for family sessions.
• 99213, 99214 (E/M office visits): Eligible for both modifiers under Medicare with POS 10 when delivered via telehealth, but state Medicaid programs vary widely on audio-only E/M reimbursement.
• H0004, H2019 (SUD counseling codes): Medicaid-reimbursed SUD codes have inconsistent telehealth modifier eligibility by state. Several state Medicaid programs still exclude H-code telehealth for audio-only entirely.
• 90791 (Psychiatric diagnostic evaluation): High-dollar code, high-scrutiny. Audio-only coverage for 90791 is specifically excluded by several Blue Cross Blue Shield affiliates as of 2025-2026 contract cycles.

If your SUD practice is billing H-codes alongside drug screen codes, the modifier error compounds quickly. We have written separately about how SUD practices are already leaving significant revenue on the table through drug screen under-coding, and you can read that analysis at our G0480-G0483 post here. Layering telehealth modifier errors on top of that is a compounding revenue problem, not an isolated one.

What a Denial Pattern Actually Looks Like in Your AR

We pull denial data quarterly across our client portfolio and the telehealth modifier denial codes cluster around specific CARC/RARC combinations. The ones flagged most frequently for modifier 93 and 95 errors include:

• CARC 4: The service is inconsistent with the modifier.
• CARC 97: The benefit for this service is included in the payment or allowance for another service that was already adjudicated.
• CARC 167: This service was not covered because the payer does not cover this type of service for the patient’s age.
• RARC N95: This provider type or specialty may not bill this service.

CARC 4 with a telehealth modifier is almost always a fixable denial. The appeal window under most commercial plans is 90 to 180 days. For a 10-clinician practice billing 400 telehealth encounters per month at an average allowed amount of $130 per session, a 20% denial rate on telehealth claims represents $10,400 per month in at-risk revenue. Even recovering 65% of those denials on appeal returns $6,760 per month, or approximately $81,000 per year. That is not a rounding error.

Payer-Specific Rules You Need Documented Internally

Federal rules set the floor. Commercial payers set the ceiling. Medicare’s telehealth policy under the Consolidated Appropriations Act extensions allows modifier 93 for audio-only through the end of the current extension period, but commercial payers are not obligated to follow that standard. We track the following payer positions as of 2026:

• UnitedHealthcare: Accepts modifier 93 for most behavioral health CPT codes with POS 10, but requires a specific audio-only notation in the clinical record accessible upon request.
• Aetna: Has narrowed modifier 93 coverage for psychiatric codes, requiring prior authorization for audio-only psychiatric diagnostic evaluations (90791) in several states.
• Cigna/Evernorth: Generally follows Medicare telehealth guidelines but applies its own clinical edit that flags practices with more than 35% of telehealth claims under modifier 93.
• State Medicaid programs: Each state has its own fee schedule. Some states have codified audio-only behavioral health coverage permanently; others allowed it temporarily during the PHE and have since reverted.

The parity angle matters here too. When a commercial payer denies a covered behavioral health service delivered via audio-only telehealth while covering equivalent audio-only services for medical conditions, that is a potential MHPAEA violation. We have covered how to build that appeal argument in detail in our piece on mental health parity act appeals, and it is directly relevant when modifier 93 denials hit behavioral health claims disproportionately.

A Practical Modifier Selection Protocol for Your Billing Team

Before any telehealth claim drops, your billing team should be able to answer four questions from the clinical documentation:

• Was the session conducted via live two-way audio and video? If yes, modifier 95 applies. Stop there.
• Was the session audio-only? If yes, does the note document why video was not available or feasible for this patient on this date? If that documentation exists, modifier 93 may apply depending on the payer and CPT code.
• What is the patient’s location documented as? Match POS code to that location, not to your office.
• Does the payer contract or policy explicitly cover this CPT code under modifier 93? If you do not have that answer for your top five payers, that gap is costing you money right now.

Build a payer-specific modifier matrix in your PM system. It does not need to be complex. A simple grid with your top 10 CPT codes across the top and your top 10 payers down the side, marked for 93 eligibility, 95 eligibility, and documentation requirements, will reduce your telehealth denial rate materially within 60 days of implementation.

If you want a second set of eyes on your current telehealth claim performance before you build that matrix, we offer a free 30-day denial audit for behavioral health and SUD practices. We pull your actual denial data, identify the modifier error patterns, and quantify the recovery opportunity in dollars. You can schedule that directly at our audit intake calendar. Most practices that go through this process identify between $40,000 and $120,000 in recoverable revenue they were not tracking.