CPT Code Descriptor
98966 Telephone assessment and management service provided by a qualified non-physician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous seven days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion
98967 A nonphysician healthcare professional discusses, via telephone, a new health issue and possible treatment or management with an established patient, parent, or guardian. The illness is unrelated to a service provided within the last seven days and also unrelated to a service or procedure that takes place within the next 24 hours or soonest available appointment. This service includes 11 to 20 minutes of telephonic conversation.
98968 A nonphysician healthcare professional discusses, via telephone, a new health issue and possible treatment or management with an established patient, parent, or guardian. The illness is unrelated to a service provided within the last seven days and also unrelated to a service or procedure that takes place within the next 24 hours or soonest available appointment. This service includes 21 to 30 minutes of telephonic conversation.
Telephone Evaluation and Management Services On an interim basis, with respect to the PHE for the COVID-19 pandemic, CMS finalized a new policy that:
• CMS is increasing payments for Telephone Services codes 99441-99443 to match payments for similar office and outpatient visits. This would increase payments for these telephone services from a range of about $14-$41 to about $46-$110. The payments are retroactive to March 1, 2020.
• Provides separate payment for CPT codes 98966-98968 and CPT codes 99441-99443.
- CMS is finalizing work RVUs recommended by the AMA Health Care Professionals Advisory Committee (HCPAC) of 0.25 for CPT code 98966, 0.50 work RVUs for CPT code 98967, and 0.75 for CPT code 98968, and work RVUs asrecommended by the AMA Relative Value Scale Update Committee (RUC) of 0.25 for CPT code 99441, 0.50 for CPT code 99442, and 0.75 for CPT code 99443.
- CMS is finalizing the HCPAC and RUC-recommended direct PE inputs which consist of 3 minutes of post-service RN/LPN/MTA clinical labor time for each code.
- CMS is extending these telephone services to both new and established patients and will relax enforcement of the code descriptors.
- CMS added these telephone E/M codes to the list of Medicare telehealth services.
• Because services on the Medicare telehealth list are required to be furnished using both audio and video, CMS waived requirements that these telephone E/M codes be provided using video.
Disclaimer: Information provided by MGMA within this resource is for guidance purposes only. It does not constitute clinical or legal advice and does not address or dictate payer coverage or reimbursement policy.
While the Centers for Medicare & Medicaid Services (CMS) has implemented several flexibilities around Medicare telehealth services during the COVID-19 public health crisis, the Agency continues to require that most Medicare telehealth services be furnished using devices or telephones that have audio and video capabilities. Healthcare clinicians may use a telephone, so long as it has audio and video capabilities that are used for two-way, real-time interactive communication.
Update May 1: CMS is permitting use of audio-only equipment to furnish a select number of services, such as audio-only telephone E/M services (CPT codes 99441-99443 and 98966-98968) and behavioral health counseling and educational services. Unless provided otherwise, other services included on the Medicare telehealth services list must be furnished using, at a minimum, audio and video equipment. Services that may be furnished using audio-only modalities are marked as such in the list of Medicare telehealth services, which can be accessed here.
Audio-only E/M Codes (99441-99443; 98966-98968)
CMS will reimburse for audio-only telephone E/M visits using CPT codes 99441-99443 and 98966-98968. These codes were not previously reimbursed by Medicare but are covered for the duration of the public health emergency to reimburse for cases where the two-way, audio and video technology required to furnish a Medicare E/M service is unavailable.
Modality:
CPT codes 99441-99443 and 98966-98968 can be furnished using audio-only modalities, such as an audio-only telephone call.
Qualifying Patients:
These services can be furnished to both new and established patients, even though the codes are intended for established patients only and their code descriptors reflect this. During the public health emergency, CMS is exercising enforcement discretion to relax enforcement of this aspect of the code descriptors.
Qualifying Practitioners:
• CPT codes 99441-99443 describe telephone evaluation and management services by a physician or other qualified healthcare professional who may report E/M services.
• CPT codes 98966-98968 describe telephone assessment and management services by a practitioner who cannot separately bill for E/M services. CMS elaborates that this means the codes “may be furnished by, among others, LCSWs, clinical psychologists, and physical therapists, occupational therapists, and speech language pathologists when the visit pertains to a service that falls within the benefit category of those practitioners.”4
• These are time-based codes that describe 5-10 minutes of medical discussion (99441/98966); 11-20 minutes of medical discussion (99442/98967); 21-30 minutes of medical discussion (99443/98968).
National Valuation of the Codes:
Update May 1: Following MGMA advocacy, CMS is increasing payment for audio-only telephone E/M services (CPT codes 99441-99443) such that they are paid at the same rate as similar office and outpatient E/M visits, resulting in increased payments from $14-$41 to $46-$110 (e.g., to be consistent with payment rates for level 2-4 established office/outpatient E/M visits). 5 CMS is not increasing payment for CPT codes 98966-98968, which are intended for practitioners that cannot separately bill for E/M.
The national average valuation of these codes is:
• 99441 = $46.19
• 99442 = $76.15
• 99443 = $110.43
• 98966 = $14.43
• 98967 = $28.15
• 98968 = $41.14
Q1: What place of service (POS) code should I use when billing for remote services like digital E/M (99421-99423; G2061-2063)?
A1: For digital E/M (99421-99423; G2061-2063), virtual visits and check-ins (G2012, G2010), and audioonly E/M codes (99441-99443; 98966-98968), do not use POS-02 (telehealth), as these are not Medicare telehealth services. Use the POS code that reflects the applicable site of the practitioner’s normal office location.
Coding guidelines
Qualified non-physicians who may not report E/M can use CPT Codes 98966 – 98968 can be reported for virtual visits via telephone. For online visits (e.g., EHR portal, secure email, allowed digital communication) they can use CPT Codes 98970 – 98972/HCPCS codes G2061 – G2063, can be reported.
Documentation requirement
• Confirm the patient’s identity (name, date of birth, or other identifying information, particularly if you are not accessing the patient’s electronic or paper record).
• Obtain and document that verbal consent was obtained.
• Detail what occurred during the communication to establish medical necessity (e.g. description of the patient’s problem, details of the encounter).
• Document the total time spent communicating with the patient. If less than 5 minutes, do not submit G2012.
The following codes are reported by nonphysician providers who may independently bill such as physical therapists and psychologists, but are not reported for clinical staff (eg, RN) unless allowed by your payer:
98966 Telephone assessment and management service provided by a qualified nonphysician healthcare professional to an established patient, parent or guardian not originating from a related assessment and management service provided within the previous seven days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion
Guidelines and Reporting
CPT® code 99439 would be reported with CPT® code 99490 (chronic care management service, first 20 minutes of clinical staff), no more than twice per calendar month.
The following CPT® codes may not be reported with 99439 in the same calendar month: 90951-90970, 99339, 99340, 99374, 99375, 99377, 99378, 99379, 99380, 99487, 99489, 99491, 99605, 99606, 99607. In addition, if service time has been reported with CPT® codes 93792, 93793, 98960, 98961, 98962, 98966, 98967,98968, 98970, 98971, 98972, 99071, 99078, 99080, 99091, 99358, 99359, 99366, 99367, 99368, 99421, 99422, 99423, 99441, 99442, 99443, 99605, 99606, 99607 the work may NOT be counted towards the time of 99439 or 99490. For example, if the physician or QHP already provided an Online Digital E/M service for the patient (CPT® code 99421), that time may not be included in the time for the chronic care management service.
CPT® has also updated the list of codes that should not be reported in the same calendar month and for service time for CPT code 99491 (Chronic care management service provided by a physician or qualified healthcare professional)
Non-Face to Face Non-Physician Services: Telephone Services (98966-98968)
- CPT codes 98966-98968 may not be reported with 99439, 99487, 99489, 99490, 99491
CPT Code Service Description Office Facility RVUs (NonFacility/Facility)*
98966 Telephone assessment and management service provided by a qualified
nonphysician health care professional to an established patient, parent,
or guardian not originating from a related assessment and management service
provided within the previous 7 days nor leading to an assessment and management
service or procedure within the next 24 hours or soonest available appointment;
5-10 minutes of medical discussion $14.30 $12.91 0.41/0.3
TCM requires a face-to-face visit, initial patient contact, and medication reconciliation within specified time frames. The first face-to-face visit is part of the TCM service and not reported separately. Additional E/M services provided on subsequent dates after the first face-to-face visit may be reported separately. TCM requires
an interactive contact with the patient or caregiver, as appropriate, within 2 business days of discharge. The contact may be direct (face-to-face), telephonic, or by electronic means. Medication reconciliation and management must occur no later than the date of the face-to-face visit. These services address any needed coordination of care performed by multiple disciplines and community service agencies. The reporting individual provides or oversees the management and/or coordination of services, as needed, for all medical conditions, psychosocial needs, and activity of daily living support by providing first contact and continuousaccess. Medical decision-making and the date of the first face-to-face visit are used to select and report the appropriate TCM code. For 99496, the face-to-face visit must occur within 7 calendar days of the date of discharge, and medical decision-making must be of high complexity. For 99495, the face-to-face visit must occur within 14 calendar days
of the date of discharge and medical decision-making must be of at least moderate complexity.
Medical decision-making is defined by the E/M Services Guidelines. The medical decision-making over the service period reported is used to define the medical decision-making of TCM. Documentation includes the timing of the initial post-discharge communication with the patient or caregivers, date of the face-to-face visit, and the complexity of medical decision-making. Only one individual may report these services and only once per patient within 30 days of discharge. Another TCM may not be reported by the same individual or group for any subsequent discharge(s) within the 30 days. The same individual may report hospital or observation discharge services and TCM. However, the discharge service may not constitute the required face-to-face visit. The same individual should not report TCM services provided in the post-operative period of a service that the individual reported. A physician or other QHP who reports codes 99495, 99496 may not report care plan oversight services (99339, 99340), prolonged services without direct patient contact (99358, 99359), home and outpatient INR monitoring (93792, 93793), medical team conferences (99366-99368), education and training (98960-98962, 99071, 99078), telephone services (98966-98968, 99441-99443), ESRD services (90951-90970), ESRD services (90951-90970), preparation of special reports (99080), analysis of data (99091), complex chroniccare coordination services (99487-99489), medication therapy management services (99605-99607) during the time period covered by the transitional care management services codes. When reporting 99495, 99496, do not report 99421, 99422, 99423 during the same time period.
Codes 98966-98968 are non-face-to-face assessment and management services provided by a qualified nonphysician health care professional to a patient using the telephone. These codes are used to report episodes of care by the QHP initiated by an established patient or guardian of an established patient. If the telephone service ends with a decision to see the patient within 24 hours or the next available urgent visit appointment, the code is not reported; rather the encounter is considered part of the preservice work of the subsequent assessment and management service, procedure, and visit. Likewise, if the telephone call refers to a service performed and reported by the QHP within the previous seven days (either QHP requested or unsolicited patient follow-up) or within the postoperative period of the previously completed procedure, then the service(s) are considered part of that previous service or procedure. (Do not report 98966-98968 if reporting 98966-98968
performed in the previous seven days.) Note: After the end of the public health emergency (PHE), there will be no separate payment for the audio-only E/M visit codes. At the conclusion of the PHE, CMS will assign a status of “bundled” and post the RUCrecommended RVUs for these codes in accordance with our usual practice.
mInterprofessional Telephone/Internet/Electronic Health Record Consultations (99446-99449, 99451, 99452) are assessment and management services in which a patient’s treating (e.g., attending or primary) physician or other QHP requests the opinion and/or treatment advice of a physician with specific specialty expertise (the consultant) to assist the treating physician or other QHP in the diagnosis and/or management of the patient’s problem without patient face-to-face contact with the consultant. The patient for whom the interprofessional telephone/Internet/electronic health record consultation is requested may be either a new patient to the consultant or an established patient with a new problem or an exacerbation of an existing problem. However, the consultant should not have seen the patient in a face-to-face encounter within the last 14 days. When the telephone/Internet/electronic health record consultation leads to a transfer of care or other face-to-face service
(e.g., a surgery, a hospital visit, or a scheduled office evaluation of the patient) within the next 14 days or next available appointment date of the consultant, these codes are not reported.
Review of pertinent medical records, laboratory studies, imaging studies, medication profile, pathology specimens, etc. is included in the telephone/Internet/electronic health record consultation service and should not be reported separately when reporting 99446, 99447, 99448, 99449, 99451. The majority of the service time reported (greater than 50%) must be devoted to the medical consultative verbal or Internet discussion. If greater than 50% of the time for the service is devoted to data review and/or analysis, 99446, 99447, 99448, 99449 should not be reported. However, the service time for 99451 is based on total review and inter professional-communication time. If more than one telephone/Internet/electronic health record contact(s) is required to complete the consultation request (e.g., discussion of test results), the entirety of the service and the cumulative discussion and information review time should be reported with a single code. Codes 99446, 99447, 99448, 99449, 99451 should not be reported more than once within a seven-day interval. The written or verbal request for telephone/Internet/electronic health record advice by the treating/requesting physician or other QHP should be documented in the patient’s medical record, including the reason for the request. Codes 99446, 99447, 99448, 99449 conclude with a verbal opinion report and written report from the consultant to the treating/requesting physician or other QHP. Code 99451 concludes with only a written report.
Telephone/Internet/electronic health record consultations of less than five minutes should not be reported. Consultant communications with the patient and/or family may be reported using 98966, 98967, 98968, 99421, 99422, 99423, 99441, 99442, 99443 and the time related to these services is not used in reporting 99446-99449.
Do not report 99358, 99359 for any time within the service period, if reporting 99446, 99447, 99448, 99449, 99451. When the sole purpose of the telephone/Internet/electronic health record communication is to arrange a transfer of care or other face-to-face service, these codes are not reported. The treating/requesting physician or other QHP may report 99452 if spending 16-30 minutes in a service day preparing for the referral and/or communicating with the consultant. Do not report 99452 more than once in a 14-day period. The treating/requesting physician or other QHP may report the prolonged service codes 99354-99357 for the time spent on the interprofessional telephone/Internet/electronic health record discussion with the consultant (e.g., specialist) if the time exceeds 30 minutes beyond the typical time of the appropriate E/M service performed and the patient is present (on-site) and accessible to the treating/requesting physician or other QHP. If the interprofessional telephone/Internet/electronic health record assessment and management service occurs when the patient is not present and the time spent in a day exceeds 30 minutes, then the non-face-to-face prolonged service codes 99358, 99359 may be reported by the treating/requesting physician or other QHP.
Coding tip The CPT half-way point regarding time (according to CPT Professional Edition 2020): “A unit of time is attained when the mid-point is passed. For example, a half hour is attained when 16 minutes have elapsed (more than midway between zero and 30 minutes).”
