In 2008, a new set of CPT codes (98966, 98967, 98968) was published that allow for the reporting of clinical telephone calls managed by “qualified nonphysician health care professionals,” (e.g., registered nurses).
For several months after the codes were published, it was not clear who could report them. According to vignettes in the CPT manual, qualified nonphysician health care professionals referred to registered dietitians and physical therapists. It also was known that the term “qualified nonphysician health care professional” was not synonymous with the Centers for Medicare & Medicaid Services’ term “nonphysician practitioners,” which is limited to nurse practitioners, clinical nurse specialists and physician assistants.
Most state nurse practice acts allow registered nurses to gather subjective and objective data as part of a nursing assessment. Yet, registered nurses are usually not given the authority to interpret data, make a working diagnosis, or create a care plan. However, nurses can make an assessment and then follow pre-approved standing orders in the form of telephone triage guidelines.
Therefore, registered nurses who perform telephone triage can be considered “qualified healthcare professionals” if certain criteria are met:
The service provided falls within the state scope of practice laws for that qualified health care professional.
Established practice protocols are followed.
The physician assumes responsibility for the practice expense, quality and professional liability of the telephone services provided, whether by employing the clinical staff or via a legal contract with a telephone advice entity.
The patient is established (i.e., not a new patient).
All patient charges originate only from the physician’s office and not from an outsourced call center or other entity.
Eligibility for reporting depends on the nature of the telephone call and the status of the staff managing the call.
The codes cannot be submitted for telephone calls made by nonclinical staff (e.g., receptionists, office managers). The subject of the calls must be clinical in nature; the codes are not intended to report calls discussing insurance coverage or payment issues. Nor can these calls be used to report telephone patient encounters managed by clinical staff not qualified to conduct an independent nurse assessment as defined by state scope of practice laws. Typically, these services are limited to registered nurses, but there may be variation by state.
In essence, codes 98966-98968 mirror the physician codes for telephone services (99441-99443). Table XX shows the proper codes, qualifications, rules, and descriptors to be used with nonphysician healthcare professional telephone calls. The call must not pertain to an office visit in the preceding seven days involving the same or similar problem, nor lead to an office visit within the next 24 hours or next available appointment. Calls within these time frames are considered part of the global period related to an office visit. Payment for telephone services with this global period are bundled into the office visit payment.
Similarly, if the call is related to a medical procedure and occurs within the postoperative period, then the call is not to be reported as a separate service. Codes 98966-98968 should not be reported for multiple calls during the same seven-day period.
Proper telephone triage guidelines, policies and procedures should be followed. Calls must be documented and included in the patient chart or a separate log of telephone encounters. Calls should be reviewed by a physician and a quality assurance program implemented. Appendix XX is a sample Nurse Telephone Encounter Document.
The following vignettes exemplify the use of the codes 98966-8.
An office-based registered nurse returns an advice call about a 4 year old with fever and cough. She performs an assessment, utilized a standard cold guideline, and provides home advice including information on under which conditions to call back to the office or be seen. She spends 9 minutes on the telephone call in medical discussion. In 2008, new CPT codes (98966, 98967, 98968) were published that allow for the billing of clinical telephone calls managed by “qualified nonphysician health care professionals.” Whether nurses are considered “qualified nonphysician health care professionals” is the issue at hand. If all of the aforementioned conditions are met,this call could be reported using code 98966.
A medical assistant returns an advice call about a child with an asthma exacerbation. He spends 12 minutes going over the patient’s individual asthma action plan and recommends a course of home oral steroids. The plan is reviewed and approved by the physician in the office and the oral steroids are prescribed. A medical assistant, as well as any non-clinical staff, do not meet the criteria of a “qualified nonphysician health care provider” and therefore a fee can not be submitted for triage and advice calls performed by these individuals. This telephone call could not be reported under CPT guidelines.
An after-hours nurse from the local pediatric hospital’s nurse triage call center covering for a local pediatric practice returns a call to the mother of a 5 month old with diaper rash. A diaper rash telephone treatment guideline is used by the nurse and home care advice is provided. The practice receives a faxed documentation report and is charged by the hospital’s call center for the service. These types of calls do meet the criteria of the 98966-98968 codes provided that the call center utilizes registered nurses who follow telephone triage guidelines approved by the subscribing physicians. The call center may not submit the charge to the patient. Only the subscribing physician with whom the patient has an established physician patient relationship, may report the nurse telephone care. If the physician payer contract permits, a bill may be submitted (see chapter on billing).
Not all call centers report length of the telephone call in the documentation provided to the physician’s practice. In future contracts with the call center this could be a request made by the subscribing practice.
In the meantime, it may be acceptable to determine an estimated call time. If the nurse telephone document does not indicate the length of the telephone call the physician may contact the call center to determine the average call time for the quickest nurse. It is rare that a nurse does not spend at least five minutes on a telephone call, and usually closer to ten minutes or more. If the call duration is not known, but the average call time for the call center’s quickest nurse is over five minutes, then 98966 may be a reasonable choice. You may need to gain acceptance of this proxy method with individual payers before using it to report. Once again, the conditions and limitations of the codes, as outlined in Table XX, must be met. Report using the appropriate code 98966-98968
|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 seven days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment
||5-10 minutes of medical discussion|
||11-20 minutes of medical discussion|
||21-30 minutes of medical discussion|
Current Procedural Terminology © 2008 American Medical Association. All Rights Reserved.
The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. This content is for informational purposes only. It is not intended to constitute financial or legal advice. A financial advisor or attorney should be consulted if financial or legal advice is desired.