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
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 excludes BCN/BCN Advantage population) 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). | 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.
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| Priority Health | Not billable by physician | |
| 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.
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, BCBSM and Priority Health do not require the patient to initiate services. BCBSM & PH will reimburse regardless of who initiates the interaction, whether the patient is new or established and regardless the service originated from a related assessment and management service provided within 7 days or leading up to an assessment and management service/procedure within the next 24 hours or soonest available appointment.
Q: When is it appropriate to use PDCM telephone codes (98966 for 5-10 minutes, 98967 for 11-20 minutes, 98968 for 21-30 minutes)?
A: Potential Uses of Phone Service Codes
- Reaching out to a patient enrolled in Care Management to discuss changes in medication or management plan
- Contacting patients to close care gaps in HEDIS
- Follow up, or document plan update after an ED visit or hospital stay
B: Inappropriate use of Phone Service Codes
- Scheduling routine appointments
- Relaying normal lab values
- Triage phone calls for typical illnesses (i.e. Sore throat, ear pain, urinary tract infection, ext.) unless the conditions above are satisfied.
*** As always, we would encourage you to contact your internal compliance department to ensure you are in alignment with your organizations policies on care management delivery to your patient population.