2025 CPT code 98968
(Active) Effective Date: N/A Revision Date: N/A Medicine - Non-Face-to-Face Nonphysician Services Medicine Services and Procedures Feed
Telephone assessment and management service, by a qualified nonphysician healthcare professional, for an established patient (or guardian); 21-30 minutes of medical discussion.
Modifiers may apply depending on the circumstances of the service. Consult the CPT manual and payer-specific guidelines for appropriate modifier use. Modifier 95 may be required for telehealth.
Medical necessity is established when the patient's condition requires a timely telephone consultation to address acute symptoms, provide necessary medical advice, and avoid unnecessary in-person visits.The need should be documented in the clinical record.
The qualified nonphysician healthcare professional is responsible for assessing the patient's concerns, providing medical advice, and documenting the encounter in the patient's chart.This may include recommending further treatment or follow-up care.
- Medicine Services and Procedures
- Medicine Services and Procedures > Non-Face-to-Face Nonphysician Services
In simple words: A nurse, physician assistant, or similar healthcare professional talks to a patient (or their parent/guardian) on the phone about a new health problem. This 21-30 minute call discusses treatment and management options, and is unrelated to recent visits or upcoming appointments.
This CPT code reports a telephone assessment and management service provided by a qualified nonphysician healthcare professional to an established patient, parent, or guardian.The service must not originate from a related assessment and management service within the previous seven days, nor lead to an assessment and management service or procedure within the next 24 hours or the soonest available appointment. The service includes 21 to 30 minutes of medical discussion.
Example 1: A patient calls with concerns about a new rash. The qualified nonphysician healthcare professional spends 25 minutes discussing the symptoms, potential causes, and recommends self-care measures and follow-up., A parent calls on behalf of their child experiencing nighttime coughing.The professional spends 28 minutes discussing the symptoms, ruling out serious conditions based on the information given, and recommends home management strategies., A patient with a history of hypertension calls to report a sudden increase in blood pressure. The professional spends 22 minutes discussing the elevated reading, ensuring proper medication adherence, and guides the patient on immediate actions, recommending an urgent visit.
* Detailed documentation of the telephone encounter, including date, time, patient's chief complaint, symptoms, discussion points, and recommendations.* Time spent in the telephone call should be clearly documented, verifying compliance with the 21-30-minute requirement.* Documentation should confirm the patient (or guardian) initiated the call.* Confirmation that the call is not related to services within the last 7 days, nor does it lead to an in-person visit within 24 hours.
** Reimbursement for this code is highly variable and dependent on payer policies. Many payers do not reimburse for codes 98966-98968, so verify coverage before billing.Accurate time documentation is crucial for proper coding.
- Revenue Code: M5D (SPECIALIST - OTHER)
- RVU: This information is not provided in the source and requires further research based on payer-specific fee schedules and RVU values.
- Global Days: Not applicable. This code represents a distinct telephone service and does not have a global period.
- Payment Status: Active, but reimbursement varies significantly by payer. Many payers do not reimburse for this code.
- Modifier TC rule: Not applicable. This code represents a complete service.
- Fee Schedule: Fee schedules vary significantly by payer and year.Historical data is not available in source but can be found using a medical billing database.
- Specialties:The code may be used by a variety of specialties, including family medicine, internal medicine, pediatrics, and others, depending on the nature of the patient's call.
- Place of Service:Office, Home, Telehealth Provided in Patient’s Home, Telehealth Provided Other than in Patient’s Home