CPT Code 98970 & 98971 | Billing, Reimbursement & Documentation Guide

Introduction: 

CPT codes 98970 and 98971 are used in medical billing to document and bill for digital evaluation and management (E/M) services provided by healthcare professionals who do not have evaluation and management services in their scope of practice, such as physical therapists, occupational therapists, and speech-language pathologists. These codes apply to non-physician practitioners providing patient assessments through electronic communications.

As telehealth and digital health services become more prevalent, understanding these CPT codes is crucial for proper billing and reimbursement.

What are CPT Codes 98970 and 98971?

Definition and Purpose

• CPT Code 98970: This code represents a digital evaluation and management service provided by a qualified healthcare professional. It covers 5–10 minutes of cumulative time spent reviewing patient information, responding to inquiries, and providing medical guidance through secure online communication.
• CPT Code 98971: This code is used when a healthcare professional spends 11–20 minutes engaged in a similar digital evaluation and management service.

These codes are essential for documenting and billing telehealth services provided asynchronously, allowing patients to communicate with their healthcare providers without needing an in-person visit.

Importance of CPT Codes 98970 and 98971 in Medical Billing and Coding

• Enables accurate billing for remote healthcare services.
• Supports continuity of care by allowing healthcare providers to assess patients digitally.
• Helps non-physician providers get reimbursed for their time spent on digital patient management.
• Ensures insurance compliance when billing for telehealth services.

Common Medical Conditions Treated with CPT Codes 98970 and 98971

Healthcare providers use these CPT codes for digital management of various conditions, including:

• Chronic disease management (diabetes, hypertension, arthritis)
• Post-surgical follow-ups (wound care, mobility guidance)
• Mental health conditions (anxiety, depression, stress management)
• Physical therapy and rehabilitation guidance
• Medication management and adjustments
• General patient education and preventive care counseling

These codes help streamline patient care, ensuring individuals receive timely responses to health concerns through electronic means.

Who Can Bill CPT Codes 98970 and 98971?

Healthcare Professionals Eligible to Use These Codes

These CPT codes are specifically designed for non-physician healthcare providers, such as:

• Physical Therapists (PTs)
• Occupational therapists
• Speech-language pathologists
• Clinical social workers
• Nutritionists and dietitians

Physicians and providers who bill E/M services under separate codes (e.g., 99421-99423) cannot use these codes.

Settings Where This Code is Applicable

CPT 98970 and 98971 can be billed in various healthcare settings, including:

• Hospitals (outpatient services)
• Clinics and private practices
• Rehabilitation centers
• Telemedicine platforms
• Home health services

These codes are beneficial for telehealth consultations that involve secure patient-provider communication via email, portals, or apps.

Related CPT Codes with 98970 and 98971 (Respective Treatments)

Codes Frequently Billed Together

CPT 98970 and 98971 may be billed alongside:

• CPT 98972: For digital assessment and management services exceeding 21 minutes.
• CPT 99421-99423: For digital evaluation and management services provided by physicians or other qualified healthcare professionals.
• CPT 99457-99458: For remote patient monitoring services, often used for managing chronic conditions.

Comparison with Similar CPT Codes

Step-by-Step Billing Method for CPT Code 98970 and 98971

1. Patient Initiates Contact: The patient must reach out via a secure digital platform (email, portal, or app).
2. Provider Reviews Patient Data: The healthcare professional assesses patient history, symptoms, and concerns.
3. Response and Evaluation: The provider formulates a response, gives medical advice, and documents the time spent.
4. Time-Based Billing Selection:
   
   • 5–10 minutes → CPT 98970
   • 11–20 minutes → CPT 98971
5. Claim Submission: The claim is submitted using the appropriate CPT code and supporting documentation.

Reimbursement Guidelines for CPT Code 98970 and 98971

Insurance and Medicare/Medicaid Policies

• Medicare coverage varies by state and provider type.
• Private insurers often cover these services if they meet policy guidelines.
• Medicaid policies depend on state-specific regulations.

Documentation Requirements for Successful Claims

• Patient’s name, date of service, and provider credentials.
• Digital communication logs showing interaction time.
• Reason for patient contact and clinical decision-making.
• Secure platform documentation (email, portal, or app).

How to Maximize Reimbursement for CPT Codes 98970 and 98971

Best Practices to Ensure Full Compensation

• Use accurate documentation to support billing.
• Ensure patient consent is obtained for digital services.
• Stay updated with payer policies for telehealth reimbursement.
• Avoid upcoding or downcoding—bill according to actual time spent.

Commonly Approved Modifiers and Documentation Tips

• Modifier 95: Indicates a telehealth service.
• Modifier GT: Used for remote patient interactions.
• Modifier GQ: For asynchronous telecommunication services.

Case Studies

Real-world examples of CPT Code 98970 and 98971 in Medical Billing

• Physical Therapy: A patient recovering from knee surgery seeks post-rehabilitation guidance via a secure patient portal. The therapist spends 15 minutes responding with detailed exercise modifications (CPT 98971 is billed).
• Speech Therapy: A speech-language pathologist reviews a patient’s therapy progress and provides feedback through an online communication system in 8 minutes (CPT 98970 is billed).

Common Billing Mistakes and How to Avoid Them

Frequent Coding Errors and Claim Denials

• Failure to document time spent → Leads to claim rejection.
• Billing for services not patient-initiated → These codes require patient-initiated contact.
• Using the wrong CPT code → Physicians should bill 99421-99423 instead.

Strategies to Prevent Billing Mistakes

• Train billing staff on CPT code guidelines.
• Maintain clear documentation of patient interactions.
• Regularly check payer policy updates.

Conclusion

CPT codes 98970 and 98971 are crucial for billing non-physician digital evaluation and management services. Proper documentation, coding accuracy, and adherence to insurance policies help maximize reimbursement and avoid claim denials. As telehealth expands, understanding and correctly utilizing these CPT codes will be increasingly essential.

FAQs

1. Can a physician bill CPT 98970 and 98971?
No, these codes are only for non-physician providers like therapists and nutritionists.

2. Are CPT 98970 and 98971 covered by Medicare?
Coverage depends on state-specific Medicare guidelines and payer policies.

3. What is the main difference between CPT 98970 and 99421?
CPT 98970 is for non-physician providers, while 99421 is for physicians and QHPs.

4. Can these codes be used for live telehealth visits?
No, they are only for asynchronous (store-and-forward) digital interactions.

5. How do I ensure my claim is approved?
Provide detailed documentation of patient communication, time spent, and clinical assessment.

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