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


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