CPT Code 98966: Billing, Reimbursement, and Documentation Guide

Introduction: What is CPT Code 98966?

CPT Code 98966 is a medical billing code used for non-face-to-face patient interactions. As telehealth and virtual consultations become more common, this code plays a crucial role in ensuring healthcare providers get reimbursed for telephone-based medical services. A proper understanding of this code helps medical professionals optimize billing and compliance while improving patient care.

What is CPT Code 98966?

Definition and Purpose

CPT Code 98966 refers to telephone assessment and management services provided by a non-physician healthcare professional to an established patient, parent, or guardian. The call must be 5 to 10 minutes long and should be related to an evaluation and management (E/M) service. Unlike video-based telehealth services, this code is specifically for audio-only interactions.

Importance of CPT Code 98966 in Medical Billing and Coding

• Ensures reimbursement for telephone consultations when an in-person visit is not required.
• Supports telemedicine expansion by providing a structured billing method for remote patient interactions.
• Helps chronic disease management by allowing follow-ups without the need for physical office visits.
• Reduces unnecessary ER and urgent care visits by enabling timely medical advice over the phone.

Common Medical Conditions Treated with CPT Code 98966

CPT Code 98966 is used for a variety of non-emergency conditions where a brief telephone consultation can provide guidance. Some common examples include:

• Chronic disease management (e.g., diabetes, hypertension, asthma)
• Medication adjustments and side effects monitoring
• Follow-up on lab results and ongoing treatment plans
• Behavioral health support for conditions like anxiety and depression
• Minor acute conditions (e.g., mild infections, cold and flu symptoms)

Who Can Bill CPT Code 98966?

Healthcare Professionals Eligible to Use This Code

Unlike physician-specific codes, CPT Code 98966 is reserved for non-physician healthcare professionals, including:

• Nurse practitioners (NPs)
• Physician assistants (PAs)
• Clinical nurse specialists (CNS)
• Licensed clinical social workers (LCSW)
• Registered dietitians (RDs)

Settings Where This Code is Applicable

• Primary care clinics – Routine follow-ups and chronic disease management
• Specialty clinics – Post-treatment guidance and medication adjustments
• Telemedicine services – Audio-only remote consultations
• Mental health and behavioral health services – Therapy check-ins and follow-ups

Related CPT Codes with 98966 (Respective Treatments)

Codes Frequently Billed Together

CPT Code 98966 is often used alongside related telehealth and evaluation codes for a more comprehensive patient care approach. Some commonly paired codes include:

• 98967 – Telephone assessment for 11-20 minutes
• 98968 – Telephone assessment for 21-30 minutes

Step-by-Step Billing Method for CPT Code 98966

To successfully bill CPT 98966, follow these key steps:

1. Verify Patient Eligibility – Confirm the patient has had an in-person or telehealth visit within the last 7 days.
2. Confirm the Interaction Type – Ensure the service is a telephone-only consultation, not video or in-person.
3. Document Key Details – Record the reason for the call, duration (5-10 minutes), and medical advice given.
4. Assign the Correct Diagnosis Code – Ensure that the primary reason for the consultation is properly coded.
5. Submit the Claim with Modifiers if Necessary – Use appropriate modifiers (e.g., 95 for telehealth services) if required by the payer.

Reimbursement Guidelines for CPT Code 98966

Insurance and Medicare/Medicaid Policies

• Medicare: CPT 98966 is covered under Medicare Part B for non-physician practitioners, but reimbursement varies.
• Medicaid: Some states cover this service under Medicaid, especially for telehealth-based care.
• Private Insurance: Coverage depends on the insurer’s policy. It’s important to verify telehealth policies with each provider.

Documentation Requirements for Successful Claims

• Patient’s medical history and reason for the call
• Detailed summary of the consultation and recommendations given
• Duration of the call (must be 5-10 minutes)
• Follow-up plan (if applicable)

How to Maximize Reimbursement for CPT Code 98966

Best Practices to Ensure Full Compensation

• Keep accurate documentation of all phone interactions.
• Verify insurance coverage before billing to reduce denials.
• Use the correct modifiers for telehealth services if required.

Commonly Approved Modifiers and Documentation Tips

• Modifier 95 – Telehealth services (may be required by private payers)
• Modifier GT – Telehealth service delivered via interactive technology (less commonly used now)
• Ensure documentation specifies that the interaction was telephone-only and met the time requirements.

Case Studies: Real-World Examples of CPT Code 98966 in Medical Billing

Case Study 1: Chronic Disease Management

A nurse practitioner calls a patient with diabetes to discuss recent blood sugar levels and adjust insulin dosage. The call lasts 8 minutes and is documented correctly. The clinic successfully bills CPT 98966 for the service.

Case Study 2: Behavioral Health Check-In

A licensed clinical social worker conducts a 7-minute check-in call with a patient undergoing anxiety treatment. The call includes counseling strategies and medication adherence guidance. CPT 98966 is billed and reimbursed accordingly.

Common Billing Mistakes and How to Avoid Them

Frequent Coding Errors and Claim Denials

• Billing for new patients (CPT 98966 is only for established patients)
• Lack of proper documentation (missing call duration and summary)
• Submitting claims for services covered within the past 7 days (not separately billable)

Strategies to Prevent Billing Mistakes

• Implement EHR templates for telehealth documentation.
• Train staff on Medicare and private insurance policies regarding CPT 98966.
• Double-check claim submissions to avoid denials and delays.

Conclusion

CPT Code 98966 is essential for billing non-face-to-face telephone consultations provided by non-physician healthcare professionals. With telemedicine on the rise, understanding this code ensures proper reimbursement while maintaining compliance with healthcare regulations. By following best practices, providers can maximize revenue and improve patient care accessibility.

FAQs

1. Can CPT 98966 be used for new patients?

No, it is only billable for established patients who have had a prior visit within the last 7 days.

2. How much does Medicare reimburse for CPT 98966?

Reimbursement rates vary but typically range between $15-$30 depending on location and payer.

3. Does CPT 98966 require patient consent?

Yes, verbal patient consent must be documented before billing for the service.

4. Can CPT 98966 be billed with telehealth video visits?

No, this code is specifically for audio-only telephone services.

5. Are there any time restrictions for CPT 98966?

Yes, the call must be between 5-10 minutes to qualify for billing.

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