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? Any licensed care-team member who has completed Introduction to Team-Based Care within 6 months of billing
| 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 |
|
| Priority Health |
Not billable by physician |
This code is not included within incentive program, effective with 2022 program year |
| 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. All services should be billed in accordance with CPT and Center for Medicare & Medicaid service guidelines.
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)