How To Use CPT Code 98968

CPT 98968 refers to a telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 98968.

1. What is CPT 98968?

CPT 98968 is a medical billing code used to describe a specific type of telephone assessment and management service provided by a qualified nonphysician health care professional. This service involves a medical discussion with an established patient, parent, or guardian, and is not related to a previous assessment and management service within the last seven days or leading to a service or procedure within the next 24 hours or soonest available appointment.

2. 98968 CPT code description

The official description of CPT code 98968 is: “Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion.”

3. Procedure

  1. The nonphysician healthcare professional receives a phone call from the patient, parent, or guardian.
  2. The professional listens to the patient’s health concerns and answers any medical questions.
  3. Recommendations for management or treatment are provided based on the discussion.
  4. The professional documents the encounter in the patient’s record, including the duration of the call (21-30 minutes).

4. Qualifying circumstances

Eligible recipients of CPT 98968 services are established patients, parents, or guardians who initiate a phone call to a qualified nonphysician health care professional. The call must not be related to a previous assessment and management service within the last seven days or lead to a service or procedure within the next 24 hours or soonest available appointment. Qualified nonphysician health care professionals include nurses, physician assistants, nurse practitioners, physical therapists, respiratory therapists, trained social workers, and similar medical professionals.

5. When to use CPT code 98968

It is appropriate to bill CPT 98968 when a qualified nonphysician health care professional provides a telephone assessment and management service to an established patient, parent, or guardian, and the call meets the specific criteria mentioned in the code description. The service must include 21-30 minutes of medical discussion and not be related to a previous assessment and management service within the last seven days or lead to a service or procedure within the next 24 hours or soonest available appointment.

6. Documentation requirements

To support a claim for CPT 98968, the following information must be documented:

  • Date and time of the call
  • Duration of the call (21-30 minutes)
  • Identity of the patient, parent, or guardian
  • Identity of the qualified nonphysician health care professional
  • Summary of the medical discussion, including health concerns, questions, and recommendations for management or treatment

7. Billing guidelines

When billing for CPT 98968, it is essential to verify the current guidelines with individual insurance companies, as many payers may not reimburse for this code. Ensure that the documentation clearly states the time involved and items discussed during the call. Be aware of the time frames associated with CPT 98968 that prevent reporting the code, such as calls within seven days of a previous E/M service or within the postoperative period from a previous procedure or surgery.

8. Historical information

CPT 98968 was added to the Current Procedural Terminology system on January 1, 2008. The code was changed on January 1, 2009, with an updated descriptor.

9. Similar codes to CPT 98968

Five similar codes to CPT 98968 and how they differ are:

  • CPT 98966: Involves 5-10 minutes of medical discussion.
  • CPT 98967: Involves 11-20 minutes of medical discussion.
  • CPT 99426: Patient education and training services.
  • CPT 99427: Complex chronic care coordination services.
  • CPT 99439: Prolonged preventive service(s).

10. Examples

  1. A patient calls a nurse practitioner to discuss new symptoms and possible treatment options. The call lasts 25 minutes.
  2. A parent calls a physician assistant to discuss their child’s recent diagnosis and management plan. The call lasts 22 minutes.
  3. A guardian calls a respiratory therapist to discuss their ward’s breathing issues and potential interventions. The call lasts 28 minutes.
  4. A patient calls a physical therapist to discuss their progress and adjustments to their exercise plan. The call lasts 23 minutes.
  5. A parent calls a nurse to discuss their child’s medication side effects and possible alternatives. The call lasts 27 minutes.
  6. A guardian calls a trained social worker to discuss their ward’s mental health concerns and support options. The call lasts 21 minutes.
  7. A patient calls a nurse practitioner to discuss their recent test results and implications for their treatment plan. The call lasts 30 minutes.
  8. A parent calls a physician assistant to discuss their child’s ongoing symptoms and the need for further evaluation. The call lasts 24 minutes.
  9. A guardian calls a physical therapist to discuss their ward’s mobility issues and potential interventions. The call lasts 26 minutes.
  10. A patient calls a respiratory therapist to discuss their breathing difficulties and possible treatment options. The call lasts 29 minutes.

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