Place of Service and Modifier 95 for a Telehealth Group Session
A community mental health agency runs a weekly 60-minute psychotherapy group (CPT 90853) for 7 patients. Historically all sessions were in the clinic (POS 11). Starting this quarter, the group meets via a HIPAA-compliant video platform, with the therapist at the clinic and all 7 patients at home in the same state. The agency's billing vendor submits all 7 claims with POS 11 and no modifier, reasoning that "the therapist is in the clinic, so POS 11 is correct." One patient was traveling out of state during a session and joined from a hotel; the vendor billed that patient the same way. The payer requires modifier 95 for synchronous telehealth and requires POS to reflect where the patient received the service.
1. Is the vendor's POS 11 reasoning correct? What POS and modifier should be used, and why?
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The vendor is wrong. POS reflects where the patient received the service, not where the clinician sat. For a patient at home receiving synchronous video psychotherapy, the correct POS is 10 (Telehealth Provided in Patient's Home) under current CMS POS guidance (or the payer's specified telehealth POS if it differs - some payers still want POS 02 for telehealth).
Modifier: The payer requires modifier 95 (synchronous telemedicine service rendered via real-time interactive audio and video). So each in-state home patient's claim should be 90853 with modifier 95 and POS 10 (per this payer's rule).
Why it matters:
- POS 11 signals an in-person office visit and can trigger a different (often higher) payment rate and different coverage rules than telehealth.
- Omitting modifier 95 when required is a claim edit failure and a coverage/audit problem.
- The clinician's physical location is irrelevant to the POS on the claim for the patient's service.
Corrected claim for the 6 in-state home patients: 90853-95, POS 10 (or payer-specified telehealth POS).
2. What about the patient who joined from an out-of-state hotel? What additional issues arise?
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Issues:
- Licensure/practice location: The clinician must be authorized to practice (and the service must be covered) where the patient is located. If the clinician is not licensed in the patient's travel state, the service may be non-billable or non-compliant regardless of coding.
- POS: The patient's location is a hotel in another state, not their home. POS 10 (home) would be inaccurate; the appropriate telehealth POS depends on the payer (often POS 02 for a location other than home, or the payer's designated telehealth POS). The claim must reflect the actual patient location.
- Payer/network: Coverage may differ by the patient's location and the payer's telehealth rules for that state.
- Group integrity: If the out-of-state connection created a licensure problem, the entire session's billing could be questioned for that patient. The clinician should document the patient's location at the time of service for every telehealth encounter.
Action: Do not auto-bill this patient with the same POS/modifier as the home patients. Confirm licensure and payer telehealth rules for the travel state, then bill with the correct POS and modifier, or treat the session as non-billable for that patient if requirements are not met.