CPT 98967 Reimbursement & Policy Benchmarks | OpenPayer

Summary & Overview

CPT 98967: Telephone Consultation by Nonphysician, 11–20 Minutes

CPT code 98967 captures a brief, telephone-based clinical discussion delivered by a nonphysician qualified healthcare professional to an established patient, parent, or guardian, lasting 11 to 20 minutes. This code matters nationally as telehealth and virtual care modalities expand access to care and present distinct billing and documentation requirements for nonphysician clinicians. Accurate use of the code affects claims processing, audit risk, and telehealth reporting across major payers.

Key payers in this national overview include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise explanation of the service definition and clinical context, common payer coverage considerations, typical sites of service, and the set of commonly used modifiers. The publication also highlights benchmarking and policy updates relevant to telephone-based nonphysician consultations, documentation expectations for time-based telephonic services, and relationships to other virtual care billing options.

This summary provides practitioners, billing staff, and policy analysts with the operational context needed to identify appropriate use cases for CPT code 98967, understand payer coverage patterns, and recognize where further documentation or coding pathways may be required. Data not available in the input is clearly noted where applicable.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareCPT 98967telephone consultationtelehealthnonphysician cliniciantime-based servicebilling guidanceremote careambulatory care

Billing Code Overview

CPT code 98967 describes a telephonic clinical discussion provided by a nonphysician qualified healthcare professional to an established patient, parent, or guardian. The service covers a focused medical conversation about a health issue and possible treatment or management that lasts 11 to 20 minutes.

Service type: Telephonic clinical consultation by nonphysician clinician
Typical site of service: Remote/telehealth (telephone-based) interactions

Clinical & Coding Specifications

Clinical Context

An established adult patient with a history of hypertension calls the clinic reporting increased home blood pressures and intermittent headaches. A licensed practical nurse or a physician assistant conducts a telephone encounter lasting 15 minutes to review recent readings, medication adherence, side effects, and to recommend nonprocedural adjustments such as reinforcing salt restriction and suggesting an office blood pressure check. The clinician documents the time spent, the medical discussion topics, assessment, and follow-up plan in the electronic medical record. The service is billed using 98967 for a nonphysician qualified healthcare professional providing 11–20 minutes of medical discussion by telephone. Typical site of service is the outpatient clinic or ambulatory care setting (telephone-based remote communication). This workflow often includes triage, focused history review, medication reconciliation, patient education, and scheduling of in-person follow-up if indicated.

Coding Specifications

Modifier	Description	When to Use
`25`	Significant, separately identifiable evaluation and management service by the same physician on the same day of a procedure	Use when a separate E/M visit is performed in addition to the telephone service on the same date by the same practitioner.

CPT 98968: Nonphysician Telephone Evaluation and Management, 21–30 Minutes

CPT-98966-TELEPHONE-NONPHYSICIAN-ESTABLISHED-PATIENT-5-10-MINUTES

CPT 98966: Telephone Assessment by Nonphysician Clinician, 5–10 Minutes

Taxonomy Code	Specialty	Notes
`163W00000X`	Physician Assistant	Common nonphysician qualified healthcare professional who provides telephone management and documents time-based telephonic counseling.
`363A00000X`	Nurse Practitioner	Frequently delivers telephonic medical management and patient education; bills under supervising physician or incident-to rules as applicable.
`367A00000X`	Clinical Nurse Specialist	Performs telephonic chronic disease management and triage within scope of practice.
`207L00000X`	Internal Medicine Physician	Supervises and may bill related E/M services; part of multidisciplinary team managing chronic conditions remotely.
`207Q00000X`	Family Medicine Physician	Oversees and coordinates telephone management for established patients across age ranges.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`I10`	Essential (primary) hypertension	Common chronic condition managed via telephone for medication adjustments, BP review, and triage.
`E11.9`	Type 2 diabetes mellitus without complications	Frequently co-managed remotely including medication adherence, glucose trends, and lifestyle counseling.
`J45.909`	Unspecified asthma, uncomplicated	Asthma symptom review and medication management are commonly handled by telephone follow-up.
`R51`	Headache	Symptom discussion and triage for escalation of care can occur via telephone.
`R07.9`	Chest pain, unspecified	Telephone triage for chest pain to determine need for urgent evaluation; documentation must support disposition.
`F41.9`	Anxiety disorder, unspecified	Behavioral health check-ins and management discussions can be provided by nonphysician clinicians via telephone.
`M54.5`	Low back pain	Follow-up for conservative management, medication effectiveness, and activity guidance commonly occurs by telephone.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`99441`	Telephone evaluation and management service by a physician or other qualified healthcare professional, 5–10 minutes of medical discussion	Shorter-duration physician telephone service; used when physician provides brief telephonic management instead of nonphysician `98967`.
`99442`	Telephone evaluation and management service by a physician or other qualified healthcare professional, 11–20 minutes of medical discussion	Physician-level telephone service comparable in time to `98967`; used when physician (not nonphysician) conducts the 11–20 minute call.
`99443`	Telephone evaluation and management service by a physician or other qualified healthcare professional, 21–30 minutes of medical discussion	Longer telephone management when the conversation exceeds the 11–20 minute window of `98967`.
`98966`	Nonphysician qualified health care professional telephone assessment and management service, 5–10 minutes of medical discussion	Used for shorter nonphysician telephone encounters; precedes or replaces `98967` for briefer calls.
`99421`	Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5–10 minutes	Asynchronous digital service that may be used instead of a telephone call when communication occurs over secure messaging.

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