Monday, September 12, 2016

CPT CODE 98960, 98961, 98962 - Not separately payable

CPT  code definitions:

• 98960 -- education & training for patient self-management by a qualified, non-physician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient

• 98961 -- 2-4 patients - Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; 2-4 patient


• 98962 -- 5-8 patients - Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; 5-8 patients


Avoid claim errors for current procedural terminology codes 98960, 98961 and 98962

First Coast Service Options (First Coast) has recently seen a large number of Part A outpatient claim errors for current procedural terminology (CPT®) codes 98960, 98961 and 98962. Providers are reminded that professional services paid under the Medicare physician fee schedule (MPFS) for these codes are bundled or not valid for Medicare purposes. The Centers for Medicare & Medicaid Services (CMS) published relative values units (RVU) as a courtesy, since many private payers use this methodology when establishing their payment rates.

The CPT codes 98960, 98961 and 98962 are not separately billable services, and are either bundled into another service reported on the same day or are simply not covered. Do not report these codes to Medicare, unless required for secondary insurance.

• Verify the patient’s records to ensure you are billing the correct CPT® code

• Submit the charges as non-covered when a denial is required for the secondary payer


Separately Reimbursed:

Lactation consultations (98960) are separately reimbursed when filed by a licensed MD/DO or mid-level practitioner when the lactation consultation is the only service provided and performed by a certified lactation consultant under the general supervision of a licensed MD/DO or midlevel practitioner.

Not Separately Reimbursed:

Lactation consultations (98960) are considered not separately reimbursed and part of the E & M service when it is provided at the same time as an E&M visit.

99201-99215
99381-99397

Lactation consultations will deny as not separately reimbursed for members ( HCR and NHCR participants) when filed with a non-covered diagnosis.

If the service is provided by a Homecare Agency, the service is covered as part of the homecare
Per Diem.


Effective for dates of services on or after Sept. 1, 2013, UnitedHealthcare will implement a new policy denying reimbursement of non-physician health care professional medicine services when reported by physicians. Supported by the AMA, physicians should report evaluation and management (E/M) services (CPT codes 99201-99499) instead of the following medicine codes which are intended for use by non-physician health care professionals:


• Education and training for patient selfmanagement (CPT codes 98960-98962)


Visit Limits: 

Reimbursement is allowed for 1 (one) lactation consult in a hospital outpatient setting (clinic) and 2 (two) in the physician office setting. This also applies to multiple deliveries.

CPT code 98960 should only be filed with an ICD-9-CM diagnosis code for a lactation disorder listed below:

98960 Education and training for patient self-management by a qualified, non-physician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient


Reimbursement Guidelines

The American Medical Association Current Procedural Terminology (CPT®) Professional Edition gives the following instruction for code selection: “Select the name of the procedure or service that accurately identifies the service performed. Do not select a CPT code that merely approximates the service provided.” The American Medical Association (AMA) has developed specific CPT codes intended for use by qualified health care professionals who are not Physicians to report their services. In some instances the intended use of a procedure or service is within the description of the code. For example CPT 98960 describes education and training for patient selfmanagement by a qualified, nonphysician health care professional. In other instances the AMA has included parenthetical information in the CPT book as with CPT 96040 which says  “These services are provided by trained genetic  counselors and may include obtaining a structured family genetic history, pedigree construction, analysis for genetic risk assessment, and counseling of the patient and family.”

Conversely, the AMA instructs Physicians who provide genetic counseling and education, risk factor reduction intervention or medical nutrition therapy to use the appropriate evaluation and management codes to report these services. Existing evaluation and management codes include services such as taking a patient’s health and family history and counseling. Therefore, in accordance with correct coding guidelines, UnitedHealthcare will not reimburse nonphysician health care professional service codes listed in the Code Section below when reported by a Physician, because these codes are intended for use by nonphysician health care professionals. Physicians who provide genetic counseling, health and behavior assessment/intervention, medical nutrition therapy, education and training for patient self-management or medication therapy management should report these services using appropriate evaluation and management codes



UnitedHealthcare Community Plan will reimburse for Telehealth services which are recognized by CMS when reported with modifier GT (Interactive Telecommunications). In addition, UnitedHealthcare Community Plan recognizes that medical genetics and genetic counseling services (CPT code 96040), education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum (CPT codes 98960-98962), and alcohol and/or substance abuse screening and brief intervention services (CPT codes 99408-99409) can be effectively performed via Interactive Audio and Video Telecommunications systems; these codes will be allowed for reimbursement when reported with modifier GT. UnitedHealthcare Community Plan will also reimburse CPT codes 0188T and 0189T when these codes are reported with or without a GT modifier, since the description for these codes indicates a Telehealth service and the technology used.

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