98961: Education and training for patient self-management by a qualified, non-physician health care professional using a standard curriculum face-to-face with patient/caregiver for 30 minutes each (2-4 patients)
98962: Education and training for patient self-management by a qualified, non-physician health care professional using a standard curriculum face-to-face with patient/caregiver for 30 minutes each (5-8 patients)
Description: Group education
Delivery Method: Face-to-face, via video, or telephone (note: telephone can only be utilized if video was declined by patient)
Who Can Bill? Per BCBSM, an licensed care-team member who has completed Introduction to Team-Based Care within 6 months of billing. Per PH, a clinical staff member working under supervision of a physician, NP, or PA and who is allowed by law, regulation and facility policy to perform or assist in the performance of a specified professional service, but who does not individually report that professional service.
| Payer | Billing Allowance | Requirement |
| BCBSM/BCN/BCN Advantage | May be billed with quantity >1 Can be billed if 51% of the time threshold is met Not billable by physician On 9/20/23, BCBSM communicated providers recognized as registered dietitians with the education to support that recognition can bill in person PDCM codes (as if they are licensed). | |
| Priority Health | Not billable by physician | |
| Medicaid (varies by HMO) | Must be prescribed by physician or APP; cannot bill if beneficiary is enrolled in a diabetes or asthma education program during the same period |
Billing opportunities and reimbursement may vary depending upon organization's specific payer value-based contracts.
MICMT does not have expertise related to the Centers for Medicare and Medicaid services coverage decisions related to billing. The information contained on this site comes from publicly available sources of CMS information. Any needed clarification should come from CMS or their representatives/contractors.
Recommended Documentation
- Date of service and location of class
- Name and credentials of person facilitating the class
- Duration of class
- Diagnoses relevant to the group visits
- Nature and content and objective(s) of the training
- Total number of patients in attendance
- Individuals in attendance other than patient and relationship to patient
- Updates status on medical condition, care needs, and progress to goal(s)
Group Education FAQs
For additional PDCM FAQs, please click here
Q: Can an educational visit be conducted via telephone?
A: Yes, with appropriate documentation within medical record clearly stating that patient can’t or will not present for face-to-face visit.
Q: Can a physician bill a 98961 or 98962?
A: No.
Q: If a family member attends a training, can a care-team member submit claim on behalf of the patient?
A: No.
Q: Can a care team member bill the education group codes (98961/98962) and the ACP (S0257) simultaneously?
A: Yes, if the group is discussing ACP and the physician agrees with plan of care. All documentation should indicate what was conducted during this group education.
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Group Education Scenario
Patient has a new diagnosis of chronic kidney disease.
Patient and caregiver indicated interest in Chronic Kidney Disease Group Education class.
Patient attends with caregiver and with 3 other patients for 30 minutes. (98961)
Patient attends a second class with 6 other patients for 60 minutes. (98962)