98966: Telephone visit with 5-10 minutes of medical discussion
98967: Telephone visit with 11-20 minutes of medical discussion
98968: Telephone visit with 21-30 minutes of medical discussion
Description: Telephone assessment and management services provided by a qualified health care professional
Delivery Method: Telephone or via video
Who Can Bill? Any licensed or unlicensed care-team member, including medical assistants or community health workers, who has completed Introduction to Team-Based Care within 6 months of billing (for unlicensed care-team members, a scope of service document is also required)
| Payer | Billing Allowance | Requirement |
| BCBSM/BCN/BCN Advantage |
Not billable by physician No quantity billing Modifier 2P is payable when PDCM program was discussed with the patient, and patient declines engagement. Billable once per condition per year (specific to commercial PPO members only) |
For groups not participating in the PDCM program, if claim is submitted, it will deny as MEMBER liable. For all other groups, a claim is submitted and denies, it will deny as PROVIDER liable. BCN/BCN MA - PCMH Designated Primary Care Providers only. Specialist not eligible at this time. |
| Priority Health | Not billable by physician | Services must be provided by QHP (licensed staff) |
| Medicaid |
Not billable by physician Billing allowances may vary by HMO |
|
| Medicare |
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 Coinsurance/deductible may apply to these services CMS site reference * See page 125 * |
Health care practitioners who cannot independently bill for E/M phone visits are eligible to bill Medicare directly for their services described by CPT guidelines. Patients must have established or existing relationship Patient must provide consent for telephonic (virtual) outreach |
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(s) of Contact
- Contact duration
- Care-Team Name and Credentials
- Diagnosis discussed
- Development and/or maintenance of a shared care plan
- Names of providers contacted while coordinating care
- Discussion notes for each contact
- Patient/caregiver consent for outreach (Medicare only)
Telephonic Code FAQs
For additional PDCM FAQs, please click here
Q: Are CPT codes 98966, 98967 and 96968 appropriate for contacting members for emergency department visits or hospitalizations when not part of transition of care services?
A: Yes, these codes can be submitted based upon duration of time spent on the telephonic outreach with patient/caregiver.
Q: Can the PDCM codes be billed simultaneously?
A: Yes, each of the codes maybe billed alongside the other codes. As an example, G9002 can be billed on the same day as a telephonic service (98966, 98967 and 98968).
As a reminder, care coordination services (99487/99489) is time accumulated over a course of a month, not time spent within a specific day. The best practice is to bill at the end of the month, adding up all the minutes.
Q: Can a group visit (98961 or 98962) and a phone visit (98966, 98967, 98968) be billed on the same day?
A: These codes should only be billed on the same day if contact is completed as a distinct service. (e.g., Patient attends group education in the morning and the care team member contacts patient as a follow up in the afternoon).
Q: Per CPT guidelines, a patient is required to initiated telephonic outreach when using the telephonic services.
A: Yes, however BCBSM and Priority Health do not require the patient to initiate services. Both payers will reimburses for services initiated by a qualified health care professional