CPT code 98967 – Nonphysician telephone assessment, 11-20 minutes

Key takeaways

CPT code 98967 covers 11-20 minutes of telephone assessment and management by a qualified nonphysician health care professional for an established patient

Physicians, NPs and PAs report E/M services, so they don’t use 98967; their telephone codes 99441-99443 were deleted on January 1, 2025

From 2025 those providers bill audio-only E/M codes 98008-98015, or 99202-99215 with modifier 93 for Medicare, which treats 98008-98015 as invalid

Document the minutes of medical discussion. Calls tied to a related service in the prior 7 days, or followed by a visit within 24 hours, aren’t billable

Medicare telehealth flexibilities, including the 98966-98968 telephone codes for PTs, OTs and SLPs, run through December 31, 2027 (Consolidated Appropriations Act, 2026). Coverage for other nonphysician professionals and other payers varies, so verify per payer

Pabau, the billing and practice software we build, scrubs each 98967 claim for missing or invalid details before it reaches the payer

CPT code 98967: Official descriptor and code overview

CPT code 98967 is a telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian. It covers 11-20 minutes of medical discussion. The American Medical Association places it in the nonphysician telephone services family. Those codes sit apart from office visit E/M codes because no face-to-face encounter occurs.

The code applies only to established patients. New patients, meaning those not seen in the practice within the past three years, don’t qualify under this code family.

Who can bill CPT code 98967: Eligible provider types

CPT code 98967 is reported by qualified nonphysician health care professionals who cannot report evaluation and management (E/M) services. Providers who can report E/M use E/M codes for telephone visits instead. They include physicians, nurse practitioners, physician assistants, clinical nurse specialists, and certified nurse midwives.

Eligible provider types typically include the list below, though payer credentialing still decides who gets paid:

• Physical therapists (PTs)
• Occupational therapists (OTs)
• Speech-language pathologists (SLPs)
• Registered dietitians and nutrition professionals
• Clinical psychologists
• Licensed clinical social workers (LCSWs)
• Licensed professional counselors and marriage and family therapists, where payer policies allow

Incident-to billing caution: A call billed under a supervising physician’s NPI follows the physician’s coding rules, so 98967 doesn’t apply. Before 2025, that meant 99441-99443. For 2025 and later dates of service, use 98012-98015 where the payer accepts them, or 99212-99215 with modifier 93 for Medicare. Billing 98967 under a physician’s NPI is a coding error and a common audit target.

Time requirement for CPT 98967: The 11-to-20-minute threshold

The 11-to-20-minute threshold for CPT code 98967 counts minutes of medical discussion, not the total clock duration of the call. It covers the clinical conversation: assessing the issue and agreeing the plan with the patient, parent, or guardian. Time spent on hold, retrieving records, or completing administrative tasks after the call ends does not count.

Calls under 5 minutes of medical discussion aren’t reportable with this family. When a call runs exactly 10 minutes, bill 98966. At exactly 11 minutes, 98967 applies. Upcoding to 98967 for a 9-minute call is a documentation error that auditors catch quickly because the medical record’s time notation contradicts the submitted code. The right-hand column is history only: the AMA deleted 99441-99443 on January 1, 2025, and they have no tier-for-tier replacement.

What CPT code 98967 covers and what it excludes

CPT code 98967 covers calls about a new or worsening issue that needs assessment and a plan of care. The patient or a caregiver makes contact with the professional. The call must not lead to a visit or procedure within the next 24 hours or at the soonest available appointment.

Qualifying scenarios include medication management calls and follow-up questions on a new diagnosis not yet addressed in a visit. Assessing a symptom that resolves with the phone consultation also qualifies. Note in the record that the encounter stayed audio-only. A call that turns into a video visit routes to a different code family.

Excluded scenarios (not separately billable):

• Calls originating from a related E/M service provided within the prior 7 days (the call is considered part of that visit)
• Calls that lead to an in-person or telehealth visit within the next 24 hours or at the soonest available appointment
• Calls within a surgical global period for a post-operative matter related to the surgery
• Calls that solely involve prescription refills with no clinical assessment component
• Calls to schedule or confirm appointments

Put together, the provider, exclusion, and time rules form four checks that run in the order a coder meets them.

Documentation requirements for CPT code 98967

Documentation requirements for CPT code 98967 are specific: The medical record must contain all five elements below. Missing even one is sufficient grounds for denial or recoupment on audit. Thorough medical billing documentation for telephone E/M starts before the call ends, not at the end of the day.

Medicare coverage and reimbursement for CPT code 98967

Medicare can pay for CPT code 98967, but coverage depends on who makes the call and when. The COVID-19 public health emergency (PHE) ended in May 2023. Congress has since extended Medicare’s telehealth flexibilities through December 31, 2027, under the Consolidated Appropriations Act, 2026. Until that date, physical therapists, occupational therapists, and speech-language pathologists can bill 98966-98968.

Audio-only care still qualifies under that extension. Federal regulation (42 CFR 410.78(a)(3)) allows it when the patient is at home and can’t use video or doesn’t consent to it. Those claims carry modifier 93. Coverage for other nonphysician professionals depends on their practitioner type, so confirm it with your Medicare Administrative Contractor (MAC) before billing.

Medicare Advantage plans set their own telephone benefits on top of that baseline, and their rules can differ from fee-for-service Medicare. Verify with the patient’s specific plan before billing. The CMS Physician Fee Schedule lookup tool shows the national non-facility rate for 98967 by year and locality.

Reimbursement note: Confirm the national non-facility rate for CPT code 98967 against the current Medicare Physician Fee Schedule. Rates change every year and are adjusted by the Geographic Practice Cost Index (GPCI). Commercial payer rates differ from Medicare and are negotiated separately.

Payer-specific rules: Commercial insurance and Medicaid

Commercial payer coverage for CPT code 98967 varies widely. Some large carriers cover telephone E/M under their telehealth benefit; others classify phone-only services as non-covered and require a video component. Medicaid programs are equally inconsistent: State Medicaid agencies set their own telephone E/M policies, and coverage in one state does not predict coverage in another.

A pre-billing verification workflow reduces denials significantly. Check three things before submitting a CPT code 98967 claim under any commercial or Medicaid plan:

1. Benefits verification: Confirm whether the plan covers telephone-only E/M services or requires audio-video. Ask specifically about 98966-98968, because a general “telehealth” answer often describes video visits only.
2. Prior authorization: Some plans require PA for telephone E/M. Requirements are plan-specific and can change annually. Check the current plan policy, not last year’s reference.
3. Network credentialing: Confirm the rendering QHP’s credential type is recognized under the plan’s telephone E/M benefit. A plan may pay for a physical therapist’s telephone calls but not a counselor’s under the same policy language.

Staying current with medical billing compliance requirements matters in this code category. Payer policies for telephone services keep shifting, and Medicare’s current flexibilities end on December 31, 2027.

Modifiers and place of service codes for CPT 98967

Place of service (POS) and modifier requirements for CPT code 98967 depend on the payer and how it classifies the service. Many commercial payers don’t treat 98967 as telehealth because no video is involved, so standard telehealth modifiers can trigger a denial. For Medicare audio-only telehealth, modifier 93 may apply per your MAC’s guidance. Otherwise, follow the payer’s policy.

For a commercial payer that treats 98967 as non-telehealth, POS 11 with no telehealth modifier is the usual default. Adding modifier 95 or GT there can trigger an avoidable denial. For Medicare, follow your MAC’s telehealth POS and modifier instructions instead.

Common denial reasons for CPT 98967 and how to fix them

Denials on CPT code 98967 cluster around five root causes. Systematic denial management workflows that address each cause at the pre-submission stage prevent the majority of these rejections from reaching the payer at all.

CPT 98967 vs 99442 and the 2025 audio-only E/M codes

CPT 98967 and CPT 99442 used to be paired telephone codes for the same 11-20 minute tier. 98967 was for qualified nonphysician professionals, and 99442 was for physicians and other providers who report E/M. The AMA deleted 99441-99443 on January 1, 2025. A claim with 99442 for a 2025 or later date of service is rejected as an invalid code.

CPT 2025 replaced them with audio-only E/M codes 98008-98015. Codes 98008-98011 cover new patients and 98012-98015 cover established patients. The level is set by medical decision making or total time, as with office visits. 98967 itself stays active for nonphysician professionals.

Medicare doesn’t recognize 98008-98015 and gives them status I (invalid). For audio-only E/M, Medicare expects the office visit codes 99202-99215 with modifier 93. Commercial and Medicaid plans vary, so check which code set each payer accepts.

Use this decision point before assigning a code: Identify the rendering provider’s credential type and whose NPI goes on the claim. A nonphysician professional who cannot report E/M uses 98967. An MD, DO, NP, or PA uses the payer’s audio-only E/M route.

The AAPC’s CPT code lookup is a useful supplementary reference for verifying 98967 descriptor language and crosswalking to related codes. Our CPT reference for coders covers the neighboring telephone and office visit codes in plain language.

How claims management software prevents CPT 98967 denials

Most CPT code 98967 errors start in the workflow, not the codebook. Call minutes go unrecorded during the call. Nobody checks the rendering professional’s credential against the code, or looks back seven days for a related visit.

Pabau, the practice management and billing platform we build, catches claim errors before they turn into denials. Its claims software for practices scrubs every claim for missing or invalid details before it leaves Pabau. Rejected claims are flagged “Needs action”, with a fix link to the field that needs correcting.

For US practices, eligibility checks run through the Claim.MD clearinghouse before the appointment, so a plan that excludes telephone services shows up early. Payments settle from electronic remittance advice files, so coverage denials surface in time to appeal.

Pair those checks with a clean claim submission routine for telephone calls. Confirm the 7-day lookback, the 24-hour visit check, and the credential before the claim is built, and fewer 98967 claims come back unpaid.

Reduce CPT 98967 denials before they reach the payer

Pabau scrubs every claim for missing or invalid details and checks US eligibility through Claim.MD. Your telephone claims reach the payer complete the first time.

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Conclusion

CPT code 98967 rewards discipline more than coding knowledge. Its denials come from three rules: the wrong provider type, unrecorded minutes, and calls the 7-day or 24-hour exclusion makes non-billable.

Build those checks into the call itself, while the patient is still on the line. Then confirm coverage for the practitioner type before the claim goes out. For Medicare, keep the December 31, 2027 end date in view and recheck the rules before it arrives.

Clean telephone claims mean your therapists and counselors get paid for the calls that keep patients out of the waiting room. Book a demo to see how Pabau scrubs each claim before it reaches the payer.

Continue your research

Need a framework for managing claim denials across your practice? Denial management in healthcare covers the end-to-end workflow for tracking, appealing, and preventing recurring rejections.

Want to understand how clearinghouse submission works? Medical claims clearinghouse explains how electronic claims move from practice to payer and where denials originate.

Billing telehealth and telephone services together? Revenue cycle management provides the operational framework for managing both synchronous and asynchronous claim types in a single workflow.

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