CPT Code 98972: Online Digital Assessment & Management Service by a Qualified Nonphysician Health Care Professional

Introduction

In today’s digital healthcare landscape, CPT Code 98972 plays a crucial role in providing online digital assessment and management services by qualified nonphysician healthcare professionals. This code allows providers such as nurse practitioners (NPs), physician assistants (PAs), physical therapists (PTs), and other healthcare specialists to engage in remote patient monitoring and virtual care without in-person visits.

With the rise of telemedicine and digital health services, CPT 98972 ensures that healthcare professionals can bill for managing patient care via secure digital communication, including messaging, email, or online portals.

What is CPT Code 98972?

Definition and Purpose

• CPT 98972 refers to an online digital evaluation and management service performed by a nonphysician healthcare provider for an established patient who requires medical guidance through a secure digital communication platform.
• This service typically includes reviewing patient inquiries, medical history, and test results and providing treatment recommendations.

Importance of CPT 98972 in Medical Billing and Coding

• Supports remote patient care by allowing healthcare providers to monitor and manage patients without in-person visits.
• Expands access to telehealth services for patients with chronic conditions, post-surgical care needs, or mobility limitations.
• Ensures proper reimbursement for digital health services under Medicare, Medicaid, and private insurance.

Common Medical Conditions Treated with CPT Code 98972

1. Chronic Disease Management

• Diabetes (ICD-10: E11.9)
• Hypertension (ICD-10: I10)
• Chronic Obstructive Pulmonary Disease (COPD) (ICD-10: J44.9)

2. Post-Surgical Follow-Ups

• Orthopedic surgery recovery
• Wound care monitoring
• Medication adjustments

3. Behavioral and Mental Health Management

• Anxiety disorders (ICD-10: F41.9)
• Depression (ICD-10: F32.9)
• ADHD follow-up (ICD-10: F90.9)

4. Rehabilitation & Physical Therapy Consultations

• Post-stroke rehabilitation (ICD-10: I69.30)
• Musculoskeletal pain management (ICD-10: M79.1)

Who Can Bill CPT Code 98972?

Eligible Healthcare Professionals

• Nurse Practitioners (NPs)
• Physician Assistants (PAs)
• Physical Therapists (PTs)
• Occupational Therapists (OTs)
• Speech-Language Pathologists (SLPs)
• Dietitians & Nutritionists

Applicable Healthcare Settings

• Outpatient Clinics
• Telehealth Platforms & Virtual Care Services
• Home Health Agencies
• Rehabilitation Centers
• Behavioral Health Clinics

Related CPT Codes for Online Digital Health Services

Codes Frequently Billed with CPT 98972

Comparison with Similar CPT Codes

Step-by-Step Billing Method for CPT Code 98972

1. Verify Medical Necessity

• The service must be patient-initiated through a secure digital platform.
• The patient must be an established patient, meaning they have had an in-person visit with the provider within the past year.

2. Document the Digital Assessment

• The provider must review the patient’s inquiry, medical history, and test results.
• A medical decision-making process must be documented.

3. Ensure Proper Time Tracking

• CPT 98972 requires at least 21 minutes of cumulative digital interaction within 7 days.
• The time includes reviewing data, formulating treatment plans, and responding to patient inquiries.

4. Submit the Claim with Proper Modifiers

• Modifier 95 – Used for synchronous (real-time) telehealth services.
• Modifier GT – Indicates a telehealth service provided via interactive audio and video.

Reimbursement Guidelines for CPT Code 98972

Insurance & Medicare Coverage

• Medicare may cover 98972 if the provider is an approved nonphysician professional.
• Private insurers may require pre-authorization for online digital assessments.
• Medicaid coverage varies by state.

Documentation Requirements for Successful Claims

• Patient consent for digital services (verbal or written)
• Date, time, and duration of the assessment
• Clinical notes detailing patient inquiries, review of data, and treatment recommendations

How to Maximize Reimbursement for CPT Code 98972

Best Practices

• Ensure digital communication occurs through a HIPAA-compliant platform (e.g., patient portals, secure messaging apps).
• Use appropriate ICD-10 codes to justify medical necessity.
• Educate patients about digital health options to encourage engagement.

Commonly Approved Modifiers for CPT 98972

• Modifier 95 – If the service was provided via a synchronous telehealth platform.
• Modifier 59 – If billed separately from an in-person visit.

Case Studies

Real-World Applications of CPT Code 98972

Case 1: Chronic Disease Management via Digital Health

Patient Profile:

• Name: David R. (fictional)
• Age: 55
• Condition: Type 2 Diabetes
• Symptoms: Unstable blood sugar levels, fatigue, frequent urination

Scenario

David, a long-term diabetes patient, began experiencing fluctuating blood sugar levels after changing his diet. Instead of scheduling an in-person visit, he used his healthcare provider’s patient portal to submit questions and upload his glucose log for review.

Process:

1. The nurse practitioner (NP) received David’s inquiry and reviewed his glucose readings for the past two weeks.

2. A digital assessment was conducted, evaluating potential causes, such as dietary changes, medication adherence, and activity levels.

3. The NP provided recommendations via secure messaging, suggesting dietary modifications, medication adjustments, and self-monitoring strategies.

Outcome:

• David received timely intervention without the need for an in-person visit.
• The NP documented over 21 minutes of assessment and management time, meeting the criteria for CPT 98972 billing.
• The claim was approved by Medicare, ensuring proper reimbursement for digital healthcare services.

Case 2: Virtual Physical Therapy Consultation for Post-Surgical Recovery

Patient Profile:

• Name: Sarah M. (fictional)
• Age: 40
• Condition: ACL Reconstruction Recovery
• Symptoms: Swelling, knee pain, limited mobility

Scenario:

Sarah, a patient recovering from ACL reconstruction surgery, reported increased swelling and discomfort after a home therapy session. Instead of visiting the clinic, she used her rehabilitation center’s online portal to describe her symptoms and upload a short video of her knee movement.

Process:

1. A physical therapist (PT) reviewed Sarah’s submission and assessed her video for signs of improper movement or inflammation.

2. The PT spent 21+ minutes analyzing Sarah’s progress, comparing it to previous reports, and considering possible post-surgical complications.

3. A personalized response was sent digitally, including adjustments to her home therapy exercises, icing recommendations, and guidance on managing swelling.

Outcome:

• Sarah avoided unnecessary travel and clinic visits, benefiting from timely virtual care.
• The physical therapist successfully billed CPT 98972, documenting medical decision-making and intervention.
• Private insurance covered the claim, acknowledging the legitimacy of online physical therapy management.

Common Billing Mistakes and How to Avoid Them

Frequent Coding Errors & Claim Denials

• Billing CPT 98972 for new patients (it must be an established patient).
• Failing to document medical decision-making and response time.
• Not meeting the 21-minute time threshold.

Strategies to Prevent Errors

• Always document patient interactions and response times.
• Ensure the service is patient-initiated and medically necessary.
• Use appropriate telehealth modifiers (95, GT) for accurate billing.

Conclusion

CPT 98972 is a critical code for nonphysician healthcare professionals providing digital health assessments and remote patient management. Proper billing and documentation ensure reimbursement for online healthcare services, improving patient access and continuity of care.

FAQs

Is CPT 98972 covered by Medicare?

Yes, Medicare covers CPT 98972 if the service is provided by an eligible nonphysician healthcare professional and meets all documentation requirements.

Can CPT 98972 be used for new patients?

No, this code applies only to established patients who have had a prior in-person visit within the last 12 months.

How much time is required for CPT 98972?

A minimum of 21 minutes of cumulative digital assessment and management over 7 days is required for billing.

What communication platforms qualify for CPT 98972?

CPT 98972 can be billed for secure patient portal messaging, electronic health record (EHR) communications, and HIPAA-compliant email exchanges.

Can CPT 98972 be billed alongside telehealth visits?

Yes, but it must be separately identifiable from other E/M services and meet time documentation requirements.

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