CPT CODE AND Description
98960 – Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient – Average fee amount $25 – $35
98961 – Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; 2-4 patients
98962 – Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; 5-8 patients
Coding & Reimbursement:
Lactation consultations (98960) are separately reimbursed when filed by a licensed MD/DO or mid-level practitioners when the lactation consultation is the only service provided and performed by a certified lactation consultant under the general supervision of a licensed MD/DO or mid-level practitioner.
Lactation consultations (98960) are considered not separately reimbursed and part of the E & M service when it is provided at the same time as an E&M visit. 99201-99215, 99381-99397
lactation consultations will deny as not separately reimbursed for members (HCR and NHCR participants) when filed with a non-covered diagnosis not listed below.
If the service is provided by a Home Care Agency, the service is covered as part of the home care per diem.
The American Medical Association (AMA) has developed specific CPT codes intended for use by qualified health care professionals who are not Physicians to report their services. In some instances the intended use of a procedure or service is within the description of the code. For example CPT 98960 describes education and training for patient self-management by a qualified, nonphysician health care professional. In other instances the AMA has included parenthetical information in the CPT book as with CPT 96040 which says “These services are provided by trained genetic counselors and may include obtaining a structured family genetic history, pedigree construction, analysis for genetic risk assessment, and counseling of the patient and family.”
Conversely, the AMA instructs Physicians who provide genetic counseling and education, risk factor reduction intervention or medical nutrition therapy to use the appropriate evaluation and management codes to report these services. Existing evaluation and management codes include services such as taking a patient’s health and family history and counseling.
Therefore, in accordance with correct coding guidelines, Oxford will not reimburse nonphysician health care professional service codes (CPT 96040, 96150-96155, 97802-97804, 98960-98962 or HCPCS G0270-G0271) when reported by a Physician, because these codes are intended for use by nonphysician health care professionals. Physicians who provide genetic counseling, health and behavior assessment/intervention, medical nutrition therapy or education and training for patient self-management should report these services using evaluation and management codes. The codes listed in this policy are for reference purposes only. Listing of a service or device code in this policy does not imply that the service described by this code is a covered or on-covered health service. Coverage is determined by the Member’s plan of benefits or Certificate of Coverage. This list of codes may not be all inclusive.
There is a set of codes in the Current Procedural Terminology (CPT) codebook that describes education offered by non-physician providers. The code set which was added to CPT in 2006, codes98960-62, seems like an ideal fit for the types of services provided by technologists today; specifically education for positive airway pressure (PAP) management. The descriptor for code 98960 reads “Education and training for patient self-management by a qualified, non-physician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/ family) each 30 minutes; individual patient.”1 Codes 98961 and 98962 describe this service for two-four patients and five-eight patients respectively. While these codes may seem ideal, the term “standardized curriculum” limits the use of these codes.
Separately Reimbursed:
Lactation consultations (98960) are separately reimbursed when filed by a licensed MD/DO or mid-level practitioner when the lactation consultation is the only service provided and performed by a certified lactation consultant under the general supervision of a licensed MD/DO or midlevel practitioner.
Not Separately Reimbursed:
Lactation consultations (98960) are considered not separately reimbursed and part of the E & M service when it is provided at the same time as an E&M visit.
99201-99215
99381-99397
Lactation consultations will deny as not separately reimbursed for members ( HCR and NHCR participants) when filed with a non-covered diagnosis.
If the service is provided by a Homecare Agency, the service is covered as part of the homecare
Per Diem.
Effective for dates of services on or after Sept. 1, 2013, UnitedHealthcare will implement a new policy denying reimbursement of non-physician health care professional medicine services when reported by physicians. Supported by the AMA, physicians should report evaluation and management (E/M) services (CPT codes 99201-99499) instead of the following medicine codes which are intended for use by non-physician health care professionals:
• Education and training for patient selfmanagement (CPT codes 98960-98962)
Visit Limits:
Reimbursement is allowed for 1 (one) lactation consult in a hospital outpatient setting (clinic) and 2 (two) in the physician office setting. This also applies to multiple deliveries.
CPT code 98960 should only be filed with an ICD-9-CM diagnosis code for a lactation disorder listed below:
98960 Education and training for patient self-management by a qualified, non-physician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient
HMO, PPO, Individual Marketplace, Elite, Advantage
Codes 98960, 98961, & 98962 are only covered for diabetic or asthmatic members for the purpose of diabetic or
asthmatic education services. Codes G0108 & G0109 are only covered for diabetic members for the purpose of
diabetic education. Members diagnosed with diabetes may receive up to 10 hours of initial training within a
continuous 12-month period and up to 2 hours of follow-up training each year thereafter
Bundled Services and Supplies – professional
For dates of service on or after July 1, 2015 we are updating Section 1 of the policy to include Current Procedural
Terminology (CPT®) codes 98961 and 98962 (education and training for patient self-management by a qualified, nonphysician
health care professional) as always bundled services. We consider these services to be part of the overall care
management of the patient.
Florida Blue reimburses care coordination services within payment for specific programs or other
procedures and does not reimburse care coordinate services separately reported with procedure
codes 98961-98962, 98966-98968, 99487, 99489, G9001-G9012, S0257, S0280-S0281 or S0315.
• 98960 – Education Education and training training for patient patient self-management by a qualified, non-physician health care professional professional using a standardized standardized curriculum, face to face with the patient each 30 minutes
There is a set of codes in the Current Procedural Terminology (CPT) codebook that describes education offered by non-physician providers. The code set which was added to CPT in 2006, codes98960-62, seems like an ideal fit for the types of services provided by technologists today; specifically education for positive airway pressure (PAP) management. The descriptor for code 98960 reads “Education and training for patient self-management by a qualified, non-physician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/ family) each 30 minutes; individual patient.”1 Codes 98961 and 98962 describe this service for two-four patients and five-eight patients respectively. While these codes may seem ideal, the term “standardized curriculum” limits the use of these codes.
New Reimbursement Policy – Physicians Billing Non-physician Health Care Professional Medicine Services
Effective for dates of services on or after Sept. 1, 2013, UnitedHealthcare will implement a new policy denying reimbursement of non-physician health care professional medicine services when reported by physicians. Supported by the AMA, physicians should report evaluation and management (E/M) services (CPT codes 99201-99499) instead of the following medicine codes which are intended for use by non-physician health care professionals:
• Medical genetics and genetic counseling services (CPT code 96040)
• Health and behavior assessment/intervention (CPT codes 96150-96155)
• Medical nutrition therapy (CPT codes 97802- 97804, HCPCS codes G0270-G0271)
• Education and training for patient selfmanagement (CPT codes 98960-98962)
Education and Training for Patient Self-Management
If a practitioner has created a training curriculum for educating patients on management of their medical condition, he or she may employ a nonphysician health care professional to provide education using a standardized curriculum for patients with that disease.
• The curriculum may be modified as necessary based on the patient’s clinical needs or the patient or caregiver’s cultural norms and health literacy.
• These services are used to teach the patient or caregiver how to effectively manage the illness(es) or condition(s) or delay disease comorbidity(ies) in conjunction with the professional health care team.
• They are reported based on the total face-to-face time (each 30 minutes) and the number of patients receiving the education and training.
• CPT code 98960 is reported for each 30 minutes of education and training provided to an individual patient; code 98961 is reported when they are provided to 2 to 4 patients; and code 98962 is reported when 5 to 8 patients receive them.
• For example, if a physician has a large number of asthmatic patients in the practice, the use of a standardized curriculum emphasizing the importance of peak flow monitoring, use of preventive medications, and avoidance of overuse of rescue medications should improve patient compliance and safety for this chronic illness.
REIMBURSEMENT GUIDELINES
The American Medical Association Current Procedural Terminology (CPT®) Professional Edition gives the following instruction for code selection: “Select the name of the procedure or service that accurately identifies the service performed. Do not select a CPT code that merely approximates the service provided.”The American Medical Association (AMA) has developed specific CPT codes intended for use by qualified health care
professionals who are not Physicians to report their services. In some instances the intended use of a procedure or service is within the description of the code. For example CPT 98960 describes education and training for patient selfmanagement by a qualified, nonphysician health care professional. In other instances the AMA has included parenthetical information in the CPT book as with CPT 96040 which says “These services are provided by trained genetic counselors and may include obtaining a structured family genetic history, pedigree construction, analysis for genetic risk assessment, and counseling of the patient and family.”
Conversely, the AMA instructs Physicians who provide genetic counseling and education, risk factor reduction intervention or medical nutrition therapy to use the appropriate evaluation and management codes to report these services. Existing evaluation and management codes include services such as taking a patient’s health and family history and counseling.
Therefore, in accordance with correct coding guidelines, Oxford will not reimburse nonphysician health care professional service codes (listed in the Applicable Codes section below) when reported by a Physician, because these codes are intended for use by nonphysician health care professionals. Physicians who provide genetic counseling, health and behavior assessment/intervention, medical nutrition therapy or education and training for patient selfmanagement should report these services using evaluation and management codes.
UHC Guidelines
Reimbursement
UnitedHealthcare Community Plan will reimburse for Telehealth services which are recognized by CMS when reported with modifier GT (Interactive Telecommunications). In addition, UnitedHealthcare Community Plan recognizes that medical genetics and genetic counseling services (CPT code 96040), education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum (CPT codes 98960-98962), and alcohol and/or substance abuse screening and brief intervention services (CPT codes 99408-99409) can be effectively performed via Interactive Audio and Video Telecommunications systems; these codes will be allowed for reimbursement when reported with modifier GT. UnitedHealthcare Community Plan will also reimburse CPT codes 0188T and 0189T when these codes are reported with or without a GT modifier, since the description for these codes indicates a Telehealth service and the technology used.
Any other service reported with modifier GT that is not recognized by CMS will not be reimbursed.
UnitedHealthcare Community Plan Codes Recognized with Modifier GT
UnitedHealthcare will consider reimbursement for a procedure code/modifier combination using modifier GQ to report Asynchronous Telecommunications only when the modifier has been used appropriately.
Coding relationships for modifier GQ are administered through the UnitedHealthcare Procedure to Modifier Policy. UnitedHealthcare Community Plan will not reimburse for HCPCS code T1014 (Telehealth transmission, per minute, professional services bill separately) because these services are included in Telehealth services.
Telemedicine Services
Telephone Calls UnitedHealthcare Community Plan follows CMS guidelines and does not reimburse for telephone charges submitted with CPT codes 98966-98968 or 99441-99443 because they do not involve direct, in-person patient contact.
Internet Services
UnitedHealthcare Community Plan follows CMS guidelines and does not reimburse for CPT codes 98969 and 99444 (Online Medical Evaluation), because these services do not involve direct, in-person patient contact.
Consultation Services
UnitedHealthcare Community Plan follows CMS guidelines and does not reimburse for interprofessional telephone/Internet assessment and management services reported with CPT codes 99446-99449 because they do not involve direct, in-person patient contact.
