CPT CODE AND Description
98960 - 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; individual patient - Average fee amount $25 - $35
98961 - 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 patients
98962 - 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
Coding & Reimbursement:
Lactation consultations (98960) are separately reimbursed when filed by a licensed MD/DO or mid-level practitioners 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 mid-level practitioner.
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 not listed below.
If the service is provided by a Home Care Agency, the service is covered as part of the home care per diem.
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 self-management 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, Oxford will not reimburse nonphysician health care professional service codes (CPT 96040, 96150-96155, 97802-97804, 98960-98962 or HCPCS G0270-G0271) 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 or education and training for patient self-management should report these services using evaluation and management codes. The codes listed in this policy are for reference purposes only. Listing of a service or device code in this policy does not imply that the service described by this code is a covered or on-covered health service. Coverage is determined by the Member’s plan of benefits or Certificate of Coverage. This list of codes may not be all inclusive.
There is a set of codes in the Current Procedural Terminology (CPT) codebook that describes education offered by non-physician providers. The code set which was added to CPT in 2006, codes98960-62, seems like an ideal fit for the types of services provided by technologists today; specifically education for positive airway pressure (PAP) management. The descriptor for code 98960 reads “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.”1 Codes 98961 and 98962 describe this service for two-four patients and five-eight patients respectively. While these codes may seem ideal, the term “standardized curriculum” limits the use of these codes.
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
HMO, PPO, Individual Marketplace, Elite, Advantage
Codes 98960, 98961, & 98962 are only covered for diabetic or asthmatic members for the purpose of diabetic or asthmatic education services. Codes G0108 & G0109 are only covered for diabetic members for the purpose of diabetic education. Members diagnosed with diabetes may receive up to 10 hours of initial training within a continuous 12-month period and up to 2 hours of follow-up training each year thereafter
Bundled Services and Supplies – professional
For dates of service on or after July 1, 2015 we are updating Section 1 of the policy to include Current Procedural Terminology (CPT®) codes 98961 and 98962 (education and training for patient self-management by a qualified, nonphysician health care professional) as always bundled services. We consider these services to be part of the overall care management of the patient.
Florida Blue reimburses care coordination services within payment for specific programs or other procedures and does not reimburse care coordinate services separately reported with procedure codes 98961-98962, 98966-98968, 99487, 99489, G9001-G9012, S0257, S0280-S0281 or S0315.
98960 - 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; individual patient - Average fee amount $25 - $35
98961 - 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 patients
98962 - 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
Coding & Reimbursement:
Lactation consultations (98960) are separately reimbursed when filed by a licensed MD/DO or mid-level practitioners 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 mid-level practitioner.
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 not listed below.
If the service is provided by a Home Care Agency, the service is covered as part of the home care per diem.
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 self-management 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, Oxford will not reimburse nonphysician health care professional service codes (CPT 96040, 96150-96155, 97802-97804, 98960-98962 or HCPCS G0270-G0271) 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 or education and training for patient self-management should report these services using evaluation and management codes. The codes listed in this policy are for reference purposes only. Listing of a service or device code in this policy does not imply that the service described by this code is a covered or on-covered health service. Coverage is determined by the Member’s plan of benefits or Certificate of Coverage. This list of codes may not be all inclusive.
There is a set of codes in the Current Procedural Terminology (CPT) codebook that describes education offered by non-physician providers. The code set which was added to CPT in 2006, codes98960-62, seems like an ideal fit for the types of services provided by technologists today; specifically education for positive airway pressure (PAP) management. The descriptor for code 98960 reads “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.”1 Codes 98961 and 98962 describe this service for two-four patients and five-eight patients respectively. While these codes may seem ideal, the term “standardized curriculum” limits the use of these codes.
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
HMO, PPO, Individual Marketplace, Elite, Advantage
Codes 98960, 98961, & 98962 are only covered for diabetic or asthmatic members for the purpose of diabetic or asthmatic education services. Codes G0108 & G0109 are only covered for diabetic members for the purpose of diabetic education. Members diagnosed with diabetes may receive up to 10 hours of initial training within a continuous 12-month period and up to 2 hours of follow-up training each year thereafter
Bundled Services and Supplies – professional
For dates of service on or after July 1, 2015 we are updating Section 1 of the policy to include Current Procedural Terminology (CPT®) codes 98961 and 98962 (education and training for patient self-management by a qualified, nonphysician health care professional) as always bundled services. We consider these services to be part of the overall care management of the patient.
Florida Blue reimburses care coordination services within payment for specific programs or other procedures and does not reimburse care coordinate services separately reported with procedure codes 98961-98962, 98966-98968, 99487, 99489, G9001-G9012, S0257, S0280-S0281 or S0315.