CPT 98972 Benchmarks & Reimbursement | OpenPayer

Summary & Overview

CPT 98972: Online Digital Evaluation and Management for Established Patients

CPT code 98972 is a key billing code for online digital evaluation and management services delivered by qualified nonphysician health care professionals, such as physical therapists, nurse practitioners, and clinical social workers. This code applies to established patients who require cumulative digital care totaling 21 or more minutes within a seven-day period. The service is typically provided through secure electronic communication platforms, supporting non-face-to-face patient management and follow-up.

Nationally, the adoption of 98972 reflects the growing importance of telehealth and digital care in the healthcare landscape. Major payers including Aetna, Blue Cross Blue Shield, Cigna Health, Medicare, and UnitedHealthcare recognize and reimburse for this code, underscoring its relevance across commercial and government insurance programs. Readers will gain insight into payer coverage, clinical use cases, and policy updates related to 98972, as well as benchmarks for utilization and reimbursement. The publication also explores associated taxonomies and common clinical scenarios, such as management of anxiety, depression, low back pain, and headache, highlighting the code's versatility in digital care delivery.

This summary provides a comprehensive overview of 98972, its clinical context, and payer landscape, equipping stakeholders with essential information for understanding its role in modern healthcare billing and patient management.

AetnaBlue Cross Blue ShieldCigna HealthMedicareUnitedHealthcareCPT 98972online digital evaluationnonphysician health care professionale-visittelehealthestablished patientdigital caremedical billingclinical managementpolicy update

CPT Code Overview

CPT code 98972 represents an online digital evaluation and management service provided by a qualified nonphysician health care professional for an established patient. This service covers cumulative time of 21 or more minutes over a seven-day period. The typical site of service is non-face-to-face, commonly referred to as an e-visit, where care is delivered digitally rather than in person. This code is designed to support ongoing patient management and communication through secure digital platforms, enhancing access to care and continuity for patients with established provider relationships.

Clinical & Coding Specifications

Clinical Context

An established patient with low back pain (M54.5) contacts their nurse practitioner (363L00000X) through a secure online portal. Over the course of seven days, the patient and provider exchange messages regarding symptom management, medication adjustments, and physical therapy exercises. The cumulative time spent by the provider in evaluating, managing, and responding to the patient totals 21 minutes or more. This non-face-to-face service is documented and billed using CPT code 98972, reflecting the extended digital evaluation and management provided by a qualified nonphysician health care professional.

Coding Specifications

Modifiers:

Modifier Code	Description
`95`	Synchronous Telemedicine Service Rendered via a Real-Time Interactive Audio and Video Telecommunications System
`GT`	Via interactive audio and video telecommunication systems

National Reimbursement Benchmarks

Nationally, the mean rate for CPT code 98972 is $35.44 for Medicare, while the average commercial benchmark (BUCA) is $43.00. Commercial payers such as Cigna and UnitedHealth Group report higher mean rates, at $49.40 and $51.07 respectively, compared to both Medicare and BUCA.

Rate dispersion, measured by the difference between the 75th and 25th percentiles, varies across payers. Medicare exhibits the tightest range ($2.00), indicating minimal variation in rates. In contrast, UnitedHealth Group and Cigna show the widest dispersions ($26.00 and $25.00 respectively), reflecting greater variability in commercial reimbursement.

The table and chart below present a detailed breakdown of national benchmarks for each payer, including mean rates and percentile values.

State Benchmarks

State: Alaska1 / 50

Alaska Benchmarks

Alaska exhibits a wide spread in reimbursement rates for CPT code 98972, with Blue Cross Blue Shield and UnitedHealth Group at the top end and Medicare at the lowest. The rate spread, calculated as the difference between the 75th and 25th percentiles, is most pronounced for Blue Cross Blue Shield ($30.48) and Cigna ($42.00), indicating substantial variability in commercial payer rates. In contrast, Medicare's spread is minimal ($1.00), reflecting consistent rates across localities.

Compared to national averages, Alaska's commercial payers reimburse at significantly higher levels, with mean rates for Aetna, Blue Cross Blue Shield, Cigna, UnitedHealth Group, and BUCA all well above their national benchmarks. The table and chart below present the full breakdown of payer-specific rates in Alaska, highlighting the state's elevated reimbursement environment for this code.

Key Insights for Alaska

Blue Cross Blue Shield and UnitedHealth Group offer the highest mean reimbursement rates for CPT 98972 in Alaska, both above $88.00.
Medicare is the lowest paying payer in Alaska, with a mean rate of $34.81, closely aligned with the national Medicare average.
All commercial payers in Alaska reimburse significantly above their respective national averages, with the state mean rates for Aetna, BCBS, Cigna, UnitedHealth Group, and BUCA ranging from 29% to 107% higher than national benchmarks.

98970 – Online digital assessment and management service by qualified nonphysician health care professional, for an established patient, for up to 7 days, cumulative time during the 7 days

98971-QUALIFIED-NONPHYSICIAN-HEALTH-CARE-PROFESSIONAL-ONLINE

98971 – QUALIFIED NONPHYSICIAN HEALTH CARE PROFESSIONAL ONLINE DIGITAL EVALUATION AND MANAGEMENT SERVICE ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 11‑20 MINUTES

Taxonomy Code	Specialty
`225100000X`	Physical Therapist
`363L00000X`	Nurse Practitioner
`1041C0700X`	Clinical Social Worker

Related CPT Codes

CPT Code	Description	Clinical Relationship
`98970`	Qualified nonphysician health care professional online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5‑10 minutes.	Used for shorter cumulative time (5-10 minutes) for similar online digital E/M services.
`98971`	Qualified nonphysician health care professional online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 11‑20 minutes.	Used for moderate cumulative time (11-20 minutes) for similar online digital E/M services.

Codes 98970, 98971, and 98972 are mutually exclusive for the same 7-day period and are selected based on the total time spent.
These codes are alternatives depending on the cumulative time of service.

National Reimbursement Benchmarks

The table and chart below present a detailed breakdown of national benchmarks for each payer, including mean rates and percentile values.

National Mean Rates for CPT Code `98972` by Payer

State Benchmarks

State: Alaska1 / 50

Alaska Benchmarks

Mean Reimbursement Rates by Payer for CPT 98972 in Alaska

Key Insights for Alaska

Blue Cross Blue Shield and UnitedHealth Group offer the highest mean reimbursement rates for CPT 98972 in Alaska, both above $88.00.
Medicare is the lowest paying payer in Alaska, with a mean rate of $34.81, closely aligned with the national Medicare average.
All commercial payers in Alaska reimburse significantly above their respective national averages, with the state mean rates for Aetna, BCBS, Cigna, UnitedHealth Group, and BUCA ranging from 29% to 107% higher than national benchmarks.

98970 – Online digital assessment and management service by qualified nonphysician health care professional, for an established patient, for up to 7 days, cumulative time during the 7 days

98971-QUALIFIED-NONPHYSICIAN-HEALTH-CARE-PROFESSIONAL-ONLINE

OpenPayer

Summary & Overview

CPT 98972: Online Digital Evaluation and Management for Established Patients

CPT Code Overview

Clinical & Coding Specifications

Clinical Context

Coding Specifications

National Reimbursement Benchmarks

State Benchmarks

Alaska Benchmarks

Key Insights for Alaska

Related Codes

Related Diagnoses

Related CPT Codes

National Reimbursement Benchmarks

State Benchmarks

Alaska Benchmarks

Key Insights for Alaska

Related Codes