Summary & Overview
CPT 98011: Audio-Only New Patient Evaluation with High Medical Decision Making
CPT code 98011 covers a new patient evaluation and management visit conducted via synchronous audio-only telecommunication when the encounter involves more than 10 minutes of medical discussion and meets criteria for high medical decision making or 60+ minutes of total provider time on a single date. The code formalizes billing for audio-only telemedicine used for comprehensive new-patient evaluations when video is not available or appropriate, reflecting expanded remote care options nationwide.
Key payers discussed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of how this code is defined clinically, typical sites of service, and the payer landscape relevant to audio-only telehealth claims. The publication summarizes benchmark considerations, documentation and billing elements implicit in the code definition, and recent policy activity affecting audio-only evaluation and management services. It highlights clinical contexts where a new-patient audio-only E/M might be used and outlines what to expect in payer coverage and claim adjudication at a national level.
This summary is intended for clinicians, billing professionals, and policy analysts seeking a concise briefing on CPT code 98011, its clinical scope, and its implications for telehealth practice and reimbursement.
Billing Code Overview
CPT code 98011 describes a new patient evaluation and management visit delivered using synchronous audio–only technology. The service requires more than 10 minutes of medical discussion and involves high medical decision making, and/or the provider documents 60 or more minutes of total time spent on the encounter on a single date.
Service type: Audio-only telemedicine new patient E/M visit with high complexity or extended time
Typical site of service: Remote/telehealth (patient location outside the provider’s physical office), provided synchronously via audio-only communication
Clinical & Coding Specifications
Clinical Context
A typical patient is a new adult established in a primary care or specialty clinic who requires an initial evaluation via synchronous audio-only telehealth due to lack of access to video or patient preference. Example: a 62-year-old patient with poorly controlled type 2 diabetes and congestive heart failure requests an audio-only visit because they lack a smartphone. The clinician conducts a comprehensive history, reviews recent lab results and home glucose logs, evaluates medication adherence and potential adverse effects, and performs clinical decision making of high complexity (e.g., adjusting insulin regimen, ordering urgent labs, and coordinating home health). The encounter involves more than 10 minutes of medical discussion and the provider documents total time spent on the date of service of 60 minutes or more for evaluation and management activities (direct synchronous audio contact, record review, care coordination and documentation). Typical workflow: pre-visit chart review and test ordering; synchronous audio-only visit with patient; post-call work including documentation, medication reconciliation, and coordination with pharmacy and specialists. Typical site of service is outpatient/telehealth audio-only (synchronous audio-only technology).
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
95 | Synchronous telemedicine service rendered via real-time interactive audio and video | Use when telehealth is performed with audio–video; not applicable to audio-only but often reported when permitted by payer policy |