CPT Code 98967 & 98968: Complete Guide to Telehealth Billing & Reimbursement

Introduction: What Are CPT Codes 98967 and 98968?

CPT codes 98967 and 98968 are essential in telehealth services, specifically for non-face-to-face communication. These codes cover telephone assessment and management services provided by qualified healthcare professionals who are not physicians. Understanding their use is crucial for accurate billing and reimbursement in medical practice.

What Are CPT Codes 98967 and 98968?

Definition and Purpose

• CPT Code 98967 refers to a telephone assessment and management service lasting 11–20 minutes.
• CPT Code 98968 applies to a similar service but lasts 21–30 minutes.
• These codes are typically used for established patients who require medical management, counseling, or coordination without an in-person visit.
• The main goal is to offer timely patient care while reducing unnecessary clinic or hospital visits.

Importance of CPT Codes 98967 and 98968 in Medical Billing and Coding

• These codes are vital for non-physician healthcare providers such as nurse practitioners, physical therapists, and dietitians.
• They help streamline telemedicine billing, ensuring healthcare professionals are compensated for their time.
• With the increasing demand for remote healthcare, these codes support accessibility and patient engagement.

Common Medical Conditions Treated with CPT Codes 98967 and 98968

These CPT codes are often used in managing chronic and acute conditions remotely, such as:

• Chronic Disease Management: Hypertension, diabetes, asthma, and COPD
• Mental Health Support: Anxiety, depression, and stress management
• Medication Management: Adjustments and monitoring for existing prescriptions
• Post-Operative Follow-Ups: Ensuring proper recovery without an in-person visit
• Minor Acute Conditions: Cold, flu, allergies, and infections

Who Can Bill CPT Codes 98967 and 98968?

Healthcare Professionals Eligible to Use These Codes

The primary users of these codes are:

• Nurse practitioners (NPs)
• Physician assistants (PAs)
• Physical therapists (PTs)
• Speech-language pathologists (SLPs)
• Occupational therapists (OTs)
• Dietitians and nutritionists

These professionals provide telephone-based services that involve assessing a patient’s condition, providing guidance, and coordinating care.

Settings Where These Codes Are Applicable

• Telemedicine platforms
• Outpatient clinics
• Rehabilitation centers
• Home healthcare settings
• Long-term care facilities

Since these services do not require direct physician supervision, they help expand healthcare access, especially in rural or underserved areas.

Related CPT Codes for 98967 and 98968 (Respective Treatments)

Codes Frequently Billed Together

When billing CPT 98967 and 98968, healthcare providers often use:

• CPT 98966 – Similar service but lasting 5–10 minutes
• CPT 99441-99443 – Physician-based telephone consultations
• CPT 99457 – Remote patient monitoring with interactive communication
• CPT 99490 – Chronic care management (for patients with chronic conditions)

Comparison with Similar CPT Codes

Step-by-Step Billing Method for CPT Codes 98967 and 98968

1. Verify Patient Eligibility – Ensure the patient is established.
2. Confirm Medical Necessity – Services must be medically appropriate and not related to a visit within the last 7 days.
3. Document the Call Details – Record start and end times, discussion content, and recommendations.
4. Apply the Correct CPT Code – Choose the appropriate code based on call duration.
5. Submit the Claim to Insurance – Include necessary documentation to prevent claim denials.

Reimbursement Guidelines for CPT Codes 98967 and 98968

Insurance and Medicare/Medicaid Policies

• Medicare typically does not reimburse these codes, but some commercial payers and Medicaid programs do.
• Private insurance coverage varies, so checking payer policies is essential.
• Medicaid programs may reimburse in states that support telephonic-only consultations.

Documentation Requirements for Successful Claims

To ensure smooth reimbursement, documentation must include:

• Date and time of the call
• Reason for the call
• Clinical discussion summary
• Medical advice or next steps provided
• Patient consent for telehealth communication

How to Maximize Reimbursement for CPT Codes 98967 and 98968

Best Practices to Ensure Full Compensation

• Document medical necessity
• Verify insurance coverage before the call
• Use appropriate modifiers if required by insurers
• Ensure the patient is established before billing

Commonly Approved Modifiers and Documentation Tips

• Modifier 95 – Used for synchronous telemedicine services
• Modifier GT – Indicates a service provided via interactive audio and video
• Modifier 25 – When billed with other evaluation and management services

Case Studies: Real-World Examples of CPT Codes 98967 and 98968 in Medical Billing

Case 1: Chronic Disease Management

• A nurse practitioner provides a 15-minute phone consultation for a diabetic patient adjusting insulin doses.
• Billed CPT 98967 with Modifier 95.
• Successfully reimbursed by a private insurer.

Case 2: Post-Surgical Follow-Up

• A physical therapist calls a patient 22 minutes post-knee surgery to assess pain and mobility.
• Used CPT 98968 and ensured proper documentation.
• Claim approved under state Medicaid policy.

Common Billing Mistakes and How to Avoid Them

Frequent Coding Errors and Claim Denials

• Billing for new patients (Only established patients qualify)
• Missing time documentation (Duration must be recorded)
• Inaccurate code selection (Code must match the actual call duration)

Strategies to Prevent Billing Mistakes

• Train staff on telehealth documentation best practices.
• Use EHR (Electronic Health Records) to capture call details.
• Review payer guidelines before billing.

Importance of Compliance and Audit Readiness

• Maintain accurate and complete patient records.
• Ensure all telehealth calls meet state and federal regulations.
• Be prepared for payer audits to avoid penalties.

Conclusion

CPT codes 98967 and 98968 are vital for telehealth services provided by non-physician professionals. They allow healthcare providers to offer remote patient care while ensuring proper reimbursement. Understanding their billing rules, documentation requirements, and common errors can help maximize revenue and improve patient outcomes.

FAQs

1. Can CPT codes 98967 and 98968 be used for new patients?

No, these codes are only for established patients who have had a prior in-person visit.

2. Does Medicare reimburse for CPT codes 98967 and 98968?

Medicare typically does not cover these services, but some Medicaid programs and private insurers do.

3. Can these codes be used for video consultations?

No, they are strictly for telephone-only services without video.

4. What is the difference between CPT 98967 and CPT 99442?

CPT 98967 is for non-physician providers, while CPT 99442 is for physicians.

5. What documentation is required for billing these codes?

You must record call duration, medical discussion, patient consent, and recommendations.

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