Summary & Overview
CPT 98007: Established Patient Telehealth E/M, High Complexity or 40+ Minutes
CPT code 98007 denotes a synchronous audio–video evaluation and management visit for an established patient involving high medical decision making or 40+ minutes of total provider time. The code formalizes a higher-complexity telehealth E/M level for remote care delivery and matters nationally as telemedicine remains a core modality for outpatient care, chronic disease management, and specialist follow-up. Adoption and correct use of this code affect coding accuracy, patient access, and encounter-level reporting across payers. Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of national reimbursement and coverage considerations, typical sites of service and clinical contexts appropriate for this code, common claim modifiers and billing notes, and comparisons to related E/M and telehealth codes. The summary highlights practical billing elements such as time thresholds and decision-making criteria that determine code selection. Policy updates affecting telehealth E/M coding and payer-specific documentation expectations are summarized to help billing, clinical, and compliance teams align claims with payer rules. Data not available in the input is noted where applicable.
Billing Code Overview
CPT code 98007 describes an established patient evaluation and management visit delivered using synchronous audio–video telehealth technology. The service is characterized by high medical decision making and/or 40 or more minutes of total provider time spent on the encounter on a single date. This code represents a telemedicine E/M visit for patients previously seen by the provider.
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Service type: Telehealth synchronous audio–video evaluation and management for an established patient
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Typical site of service: Ambulatory/office-based or other outpatient settings where telehealth is supported
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Clinical & Coding Specifications
Clinical Context
A 62-year-old established patient with multiple chronic conditions (type 2 diabetes mellitus, congestive heart failure, and chronic obstructive pulmonary disease) requests a scheduled synchronous audio–video telehealth visit for worsening dyspnea and increasing lower-extremity edema. The patient has had prior in-person evaluation with the same clinician and is enrolled in remote monitoring for daily weights and pulse oximetry. The provider spends 45 minutes on the encounter, including review of remote monitoring data, detailed history, review of prior imaging and labs, medical decision making at a high complexity level (adjusting diuretics, considering outpatient IV diuresis versus ED referral), and counseling the patient and caregiver. The encounter is completed entirely via a secure video platform that meets payer telehealth requirements.
Workflow steps:
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Pre-visit: Medical assistant confirms identity, reviews medications, uploads recent home weight and pulse oximeter data into the EHR.
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Synchronous visit start: Provider establishes video connection, documents consent for telehealth, reviews chief complaint and focused systems relevant to cardiopulmonary status.
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Clinical assessment: Provider reviews remote monitoring trend, past imaging, and recent labs; performs visual exam via video (respiratory effort, peripheral edema) and determines high-complexity decision making.
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Care planning and documentation: Provider modifies medication regimen, arranges urgent laboratory tests, coordinates home health nursing for IV therapy evaluation, and documents total time spent (≥40 minutes) to support coding
98007. -
Post-visit: Orders placed, follow-up arranged, visit summary and patient instructions sent electronically.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
95 | Synchronous telemedicine service rendered via real-time interactive audio and video telecommunications system | Use when payer requires telehealth modifier indicating synchronous audio–video service for an E/M visit billed with 98007. |
GT | Via interactive audio and video telecommunications system (payer-specific POS) | Alternate telehealth modifier for payers recognizing GT; use per payer guidelines. |
93 | Synchronous telehealth service rendered via audio-only (telephone) modality | Use only when the encounter was audio-only and payer permits billing with 93 — not typical for 98007 which requires audio–video. |
25 | Significant, separately identifiable evaluation and management service by the same physician on the same day as another procedure | Use when an E/M provided via telehealth is distinct from another procedure performed the same day. |
59 | Distinct procedural service | Use to indicate a distinct service when multiple services on same day are otherwise bundled; apply according to NCCI edits. |
22 | Increased procedural services | Use when work required is substantially greater than typical; document justification per payer for increased work. |
52 | Reduced services | Use when service provided is partially reduced or discontinued; document extent of reduction. |
24 | Unrelated E/M service by the same physician during a postoperative period | Use if telehealth E/M is unrelated to the global surgical period and occurs during postoperative care. |
93 | Synchronous telemedicine service rendered via audio-only (duplicate entry in raw list; included once) | See above — reserved for audio-only encounters when allowed. |
95 | (duplicate in raw list; included once) | See above. |
| Taxonomy Code | Specialty | Notes |
|---|---|---|
207Q00000X | Family Medicine | Commonly performs longitudinal telehealth chronic disease management visits using 98007. |
208D00000X | Internal Medicine | Primary specialty for complex chronic disease telehealth visits requiring high medical decision making. |
2086P0200X | Cardiology | Manages heart failure patients remotely; may conduct extended telehealth visits for medication titration and symptom management. |
2084P0800X | Pulmonary Disease | Provides telehealth assessments for COPD/respiratory complaints via video, applicable for 98007. |
363L00000X | Nurse Practitioner | Advanced practice clinicians frequently bill telehealth E/M services under appropriate supervision or credentialing. |
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|---|---|
I50.22 | Chronic systolic (congestive) heart failure | Heart failure exacerbation commonly managed via telehealth with medication adjustment and remote monitoring informing high-complexity decision making. |
E11.9 | Type 2 diabetes mellitus without complications | Common comorbidity in established patients requiring medication reconciliation and chronic disease management during extended telehealth visits. |
J44.9 | Chronic obstructive pulmonary disease, unspecified | COPD exacerbations or symptom worsening evaluated via video for respiratory status and management decisions. |
R06.02 | Shortness of breath | Symptom prompting high-complexity telehealth evaluation and potential escalation of care. |
R60.0 | Localized edema | Peripheral edema assessment via video and remote weight trends contributes to management decisions in 98007 encounters. |
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|---|---|
99453 | Remote monitoring initial setup and patient education on use of devices | Often precedes telehealth follow-up visits by establishing remote physiologic monitoring that informs the 98007 encounter. |
99454 | Remote physiologic monitoring device(s) supplies and daily recordings, each 30 days | Provides the objective home data (weights, SpO2) reviewed during a 98007 telehealth visit. |
99457 | Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified healthcare professional time | May be performed in conjunction with 98007 when remote monitoring interventions and management overlap across the month. |
99441 | Telephone evaluation and management service by a physician, 5-10 minutes of medical discussion | Used for shorter audio-only follow-ups; alternative to telehealth E/M when video not used. |
99214 | Established patient office or other outpatient visit, typically 25 minutes, moderate complexity | In-person counterpart for established patient E/M; 98007 represents a telehealth visit with high MDM and ≥40 minutes total time. |