CPT 98003 Telehealth Reimbursement & Policy | OpenPayer

Summary & Overview

CPT 98003: Telehealth New-Patient Evaluation, High Complexity

CPT code 98003 represents a new-patient evaluation and management visit provided through synchronous audio–video telehealth technology, characterized by high medical decision making or at least 60 minutes of total provider time on a single date. This code captures extended, complex telemedicine encounters that substitute for in-person new-patient visits when real-time video connection is used.

Nationally, telehealth E/M codes such as 98003 matter because they affect access to care, coding consistency, and payer coverage policies across commercial plans and public programs. Key payers addressed in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. The review outlines coverage contours and common modifiers associated with telehealth billing for complex new-patient visits.

Readers will learn the clinical intent and billing context for 98003, typical sites of service, and which payers commonly address this service. The summary highlights expected documentation elements tied to high medical decision making or prolonged encounter time, benchmarks for encounter duration, and common coding pitfalls. Where input data is missing, the content notes that information is not available. The focus is national policy and billing context rather than state-specific regulations or individualized clinical advice.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicare98003CPTtelehealthnew-patientevaluation-and-managementhigh-medical-decision-makingprolonged-servicetelemedicine

Billing Code Overview

CPT code 98003 describes a new patient evaluation and management visit delivered via synchronous audio–video technology. The service reflects a comprehensive telemedicine encounter in which the provider conducts a new-patient assessment that involves high medical decision making and/or 60 or more minutes of total provider time on a single date.

Service type: Telemedicine new-patient evaluation and management visit (synchronous audio–video)
Typical site of service: Remote/virtual (telehealth) setting with the provider and patient connected via real-time audio–video technology

Data not available in the input for associated taxonomies, ICD-10 diagnoses, and related codes.

Clinical & Coding Specifications

Clinical Context

A 56-year-old patient with multiple chronic conditions (diabetes mellitus type 2, congestive heart failure, and recent worsening dyspnea) requests an initial specialty evaluation via a synchronous audio–video telehealth visit. The provider is a board-certified cardiologist who conducts a comprehensive new-patient evaluation using secure video conferencing. The encounter involves high medical decision making due to complex comorbidity review, medication reconciliation, ordering of urgent diagnostic testing (BNP, chest x-ray, and echocardiography), and coordination of care with the primary care physician and home health. The provider spends a total of 60 minutes on the single date of service, including pre-visit chart review, the real-time video visit, and post-visit documentation and care coordination.

Workflow steps:

The patient schedules a new-patient telehealth appointment and completes intake forms and home blood pressure and weight entries in the portal.
The provider performs a pre-visit review of prior records and diagnostics (30 minutes), then conducts the synchronous audio–video exam (20 minutes) with focused history, review of systems, and visual assessment of jugular venous distension and edema, followed by real-time shared decision-making regarding urgent testing.
Post-visit, the provider documents findings, places orders for imaging and labs, completes medication changes, and communicates a care plan to the referring clinician (10 minutes).

Typical site of service: outpatient telehealth (synchronous audio–video) delivered to the patient at home or other non-facility setting.

Service type: new patient evaluation and management via synchronous audiovisual telehealth with high medical decision making and total encounter time of 60 minutes or more on a single date of service.

Coding Specifications

CPT 97813: Electroacupuncture, Initial 15-Minute Treatment

CPT-97811-ACUPUNCTURE-ADDITIONAL-15-MINUTE-CONTINUATION

CPT 97811: Acupuncture, Manual Needling — Additional 15 Minutes

CPT-98002-NEW-PATIENT-TELEHEALTH-EVALUATION-MODERATE-COMPLEXITY

CPT 98002: New Patient Telehealth E/M Visit, Moderate Complexity

CPT-98016-VIRTUAL-BRIEF-EVALUATION-ESTABLISHED-PATIENT

CPT 98016: Brief Virtual Evaluation for Established Patients

CPT-98008-NEW-PATIENT-AUDIO-ONLY-EVALUATION-AND-MANAGEMENT

CPT 98008: New Patient Audio-Only Evaluation and Management

97814-ACUPUNCTURE-1-OR-MORE-NEEDLES-WITH-ELECTRICAL-STIMULATION

CPT 97814: Acupuncture with Electrical Stimulation, 15 Minutes

97810-ACUPUNCTURE-PROCEDURES-1-OR-MORE-NEEDLES-WITHOUT-ELECTRICAL

CPT 97810: Acupuncture, Initial 15 Minutes Without Electrical Stimulation

CPT-98005-ESTABLISHED-PATIENT-TELEHEALTH-EVALUATION-20-MINUTES

CPT 98005: Established Patient Telehealth E/M Visit, Low Complexity

Modifier	Description	When to Use
`95`	Synchronous telemedicine service rendered via real-time interactive audio and video telecommunications system	Append when the service is delivered via live audio–video telehealth (commonly used by many payors).
`GT`	Via interactive audio and video telecommunications system (historic/many payors)	Used when the payor requires `GT` to indicate telehealth audiovisual delivery.
`GZ`	Item or service expected to be reasonable and necessary, but unproven; used when no specific telehealth modifier is required by policy	Applied when insurer-specific telehealth modifier not required and service is reported normally; check payor guidance.
`25`	Significant, separately identifiable E/M service by the same physician on the same day of procedure or other service	Use when a distinct E/M is provided on the same day as another procedure or test.
`22`	Unusual procedural services — increased procedural services	Use when complexity or time is substantially greater than typical and payor allows increased payment for documentation of extra work.
`23`	Unusual anesthesia	Rare for telehealth E/M but used if unusual anesthesia circumstances apply to an associated procedure billed same day.
`52`	Reduced services	Use when the service provided is partially reduced or not completed.
`53`	Discontinued procedure	Use when the procedure was started but discontinued due to extenuating circumstances.
`62`	Two surgeons	Use when co-surgeons are involved in a related procedure; generally not applicable to telehealth E/M itself but included for associated surgical workflows.
`78`	Unplanned return to the operating room by the same physician following initial procedure for a related procedure during the postoperative period	Typically for surgical workflows associated with subsequent in-person care.
`80`	Assistant surgeon	Use when an assistant surgeon is involved in an associated procedure.
`82`	Assistant surgeon when a qualified resident surgeon not available	Similar application as `80` for related in-person procedures.
`95`	(duplicate entry avoided)	(See first row)

Taxonomy Code	Specialty	Notes
207RC0000X	Cardiology	Cardiologists frequently perform complex telehealth new-patient evaluations for heart failure, arrhythmias, and chest pain triage.
208D00000X	Family Medicine	Family physicians perform comprehensive new-patient telehealth evaluations and coordinate specialty referrals.
208000000X	Internal Medicine	Internists manage complex chronic disease evaluations via telehealth, including high decision making encounters.
207RH0000X	Nurse Practitioner – Cardiac	Advanced practice providers in cardiology clinics perform extended telehealth new-patient evaluations under supervising physician arrangements.
363L00000X	Telehealth/Telemedicine Specialist	Providers with telehealth-focused roles who routinely deliver synchronous audiovisual E/M services.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`I50.32`	Chronic diastolic (congestive) heart failure	Common reason for high-complexity cardiology telehealth evaluation, medication adjustment, and ordering urgent testing.
`I50.9`	Heart failure, unspecified	Used when heart failure is the clinical concern but specifics are not yet established during the initial evaluation.
`R06.02`	Shortness of breath	Symptom driving urgent evaluation and high medical decision making in a telehealth cardiac assessment.
`E11.9`	Type 2 diabetes mellitus without complications	Common comorbidity increasing visit complexity and influencing treatment decisions.
`I48.91`	Unspecified atrial fibrillation	Arrhythmia evaluation often performed via telehealth, requiring ECG and potential anticoagulation decisions.
`Z00.00`	Encounter for general adult medical examination without abnormal findings	May be used for initial comprehensive evaluations when screening and preventive planning are part of the visit.
`R07.9`	Chest pain, unspecified	High-acuity symptom that prompts comprehensive telehealth new-patient assessment and urgent diagnostic planning.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`99204`	Office or other outpatient visit for the evaluation and management of a new patient, typically 45–59 minutes of total time, or moderate to high complexity MDM	Alternative in-person new-patient E/M code for substantial visits; may be billed when visit is in-person rather than telehealth and time/MDM levels match.
`99205`	Office or other outpatient visit for the evaluation and management of a new patient, typically 60–74 minutes of total time, or high complexity MDM	In-person new-patient E/M equivalent for visits with high MDM and prolonged total time; relates to `98003` as the in-person counterpart.
`99454`	Remote physiologic monitoring treatment management services, for device(s) that collect and transmit physiologic data	Often ordered following a telehealth evaluation for ongoing monitoring (e.g., remote weight or BP monitoring for heart failure).
`93000`	Electrocardiogram, routine ECG with at least 12 leads; tracing and interpretation	Common diagnostic test ordered after telehealth cardiac evaluations to assess arrhythmias or ischemia.
`93306`	Echocardiography, transthoracic, real-time with image documentation (complete)	Frequently ordered after a high complexity cardiology telehealth visit to evaluate cardiac structure and function.
`99457`	Remote physiologic monitoring treatment management services, physician/other qualified health care professional time in a calendar month	Used for ongoing management following the initial telehealth encounter when monitoring and remote management are required.

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