CPT code 99443 – Telephone evaluation and management service

Key Takeaways

CPT 99443 covers telephone E/M services of 21-30 minutes for established patients only – new patients are ineligible.

AMA introduced 98000-series audio-only codes in 2023; payer adoption of 99443 vs. 98013 varies – verify your payer’s current fee schedule before billing.

Most 99443 denials trace to undocumented call time, new-patient errors, or calls that led to an office visit within 24 hours.

Pabau’s claims management software routes telephone E/M claims through Claim.MD, validating codes and payer rules before submission.

CPT code 99443: Definition and key facts

CPT code 99443 is a telephone evaluation and management service code for a medical discussion lasting 21 to 30 minutes between a physician (or other qualified health care professional) and an established patient, parent, or guardian.

The American Medical Association owns and maintains the CPT code set; 99443 sits within the telephone E/M series alongside 99441 (5-10 minutes) and 99442 (11-20 minutes). All three codes apply to audio-only calls – video encounters with real-time audio-visual capability are billed under office or outpatient E/M codes instead, using telehealth software that captures both modes.

The patient must be an established patient – someone who has received professional services from the physician or an associate of the same specialty in the same group within the past three years. The call must involve medical discussion, not scheduling, refills without clinical assessment, or test-result relay alone.

Is CPT 99443 still active? 2025 and 2026 status

CPT 99443 remains in the AMA CPT code set as of 2025-2026 and has not been deleted. The confusion arises from a 2023 AMA restructure that introduced the 98000-series audio-only telehealth codes (98012 through 98016) as an expanded replacement framework for the telephone E/M series. The two series now coexist.

The practical distinction matters most at the payer level. Medicare’s coverage of 99441-99443 was expanded during the COVID-19 public health emergency but has since reverted to pre-PHE policy for fee-for-service Medicare. As of 2025, CMS does not cover 99441-99443 under Medicare fee-for-service for most clinical contexts – verify the current CMS Physician Fee Schedule and the Medicare Telehealth Services List before billing. Many commercial payers and state Medicaid programs continue to reimburse 99443, but policies vary significantly.

• AMA CPT status: Active – 99443 has not been deleted from the code set
• 98000-series relationship: 98013 and 98016 are the newer audio-only codes for established and new patients respectively; some payers have migrated to these
• Medicare fee-for-service: Coverage reverted post-PHE for most scenarios – confirm per current CMS Physician Fee Schedule
• Commercial payers: Many still reimburse 99443; verify each payer’s telehealth coverage bulletin individually
• State Medicaid: Varies by state – no blanket coverage assumption applies

What CPT 99443 covers and what it excludes

CPT 99443 covers a telephone medical discussion between a physician or other qualified health care professional and an established patient, lasting 21 to 30 minutes of cumulative medical conversation time. “Medical discussion” means clinical assessment, advice, or management – not administrative tasks.

The exclusions are where most billing errors originate. Understanding these before submission avoids the most common denial triggers.

• New patients: Ineligible – the code is restricted to established patients with prior professional-service contact in the same group within three years
• Post-operative calls: Calls within a global surgical period are bundled into the surgical fee and cannot be billed separately
• Video encounters: Real-time audio-visual calls fall under office or outpatient E/M codes, not the telephone E/M series
• Non-physician staff: Calls conducted by nurses or other non-qualified staff cannot be reported under 99443 (separate codes apply)
• Calls leading to in-person visits: If the telephone call results in an office visit within 24 hours, or the next available appointment, the call is considered part of the pre-service work and cannot be billed separately
• Test-result relay alone: A call solely to deliver lab or imaging results without a meaningful clinical discussion does not meet the medical-discussion requirement

How to bill CPT code 99443: Step-by-step

Billing CPT 99443 correctly requires verifying several eligibility conditions before the claim is submitted. Review these steps in order – a single missed check is enough to generate a denial.

1. Confirm patient eligibility and established-patient status. Run insurance eligibility verification before the call and confirm the patient has a prior professional-service encounter in the same group within three years. Document this confirmation in the record.
2. Conduct and time the call. Record the call’s start and stop time, or total minutes of medical discussion. Only the time spent on clinical discussion counts – time on hold or on administrative matters does not.
3. Confirm the call did not trigger a same-day visit. If the call results in the patient being directed to an in-person or virtual visit within 24 hours or the next available appointment slot, stop – the call cannot be billed separately under 99443.
4. Select the correct place of service (POS) code. For telehealth services: POS 02 (telehealth other than in patient’s home) or POS 10 (telehealth in patient’s home). Verify which POS applies to audio-only telephone E/M under current CMS and payer guidance.
5. Apply required modifiers. Modifier requirements vary by payer. Some payers require modifier 95 (synchronous telemedicine service) or GT (via interactive audio and video telecommunication systems) – confirm each payer’s current telehealth modifier policy before submission.
6. Attach appropriate diagnosis codes. Pair 99443 with the ICD-10-CM diagnosis code that represents the primary condition discussed on the call. The diagnosis should justify the medical necessity of the telephone encounter.
7. Submit the claim. Route through electronic claims submission via Claim.MD, which validates CPT-ICD pairing and flags payer-specific edit rules before the claim reaches the payer. Understanding medical billing fundamentals helps staff catch errors at the pre-submission stage rather than post-denial.

Documentation requirements for CPT code 99443

Auditors and Medicare Administrative Contractors (MACs) look for specific elements in the chart note supporting a 99443 claim. Missing any one of these can result in a post-payment audit recovery or a denied claim on prepayment review.

Good medical billing compliance practice requires that the note be completed on the same date as the call, not reconstructed later. A superbill that captures the code without an accompanying chart note does not satisfy documentation requirements on its own.

Medicare reimbursement for CPT code 99443

Medicare reimbursement for CPT code 99443 depends on the applicable fee schedule year and the practice’s geographic location, as the Medicare Physician Fee Schedule (MPFS) applies a geographic adjustment factor (GPCI) to each locality. Always verify the current-year rate using the CMS MPFS lookup tool rather than relying on prior-year figures, since rates change each January 1.

As of the 2025 MPFS, the national non-facility rate for 99443 is approximately $38-$46 (the exact figure depends on your MAC jurisdiction’s geographic adjustment). The facility rate is lower. You can verify RVU values and calculate location-adjusted rates using the FastRVU 2026 RVU lookup tool. For the revenue cycle management workflow, pull the current MPFS file and use it to set internal benchmarks before billing season. Electronic remittance advice (ERA) from Medicare will reflect the actual allowed amount after any geographic adjustment is applied.

One important caveat: the rate stated above is a general industry range based on publicly available 2025 MPFS data and should be verified against the actual current-year fee schedule before billing. CMS publishes updated MPFS files each year through claims management software integrations and directly on the CMS website. Practices using Pabau submit these claims through the Claim.MD clearinghouse, which references current payer fee schedules and flags rate discrepancies before claims reach the payer.

CPT 99441, 99442, and CPT code 99443: How they differ

The three telephone E/M codes are differentiated entirely by the duration of the medical discussion. Selecting the wrong code is straightforward to catch in audit because time documentation either supports the billed code or it does not.

There is no fourth code in this series for calls exceeding 30 minutes. If a telephone medical discussion runs beyond 30 minutes, coders report 99443 for the first 30 minutes and add-on code 99417 (prolonged outpatient E/M, per additional 15 minutes) – subject to payer policy on whether 99417 is accepted alongside telephone E/M codes. Confirm this with each payer before billing the combination.

CPT code 99443 vs. 98013 and 98016: The 2023 replacement codes

CPT 98013 is an audio-only telehealth code for established patients covering 11-20 minutes of medical discussion, while CPT 98016 is an audio-only telehealth new-patient code – making 98016 the first code in this space to allow new patients, a restriction the 99441-99443 series never lifted. The AMA CPT Editorial Panel introduced the 98000-series in 2023 as a more granular framework that separates audio-only telehealth from traditional telephone E/M.

The critical question for billing teams is which series a given payer accepts in 2025-2026. Some commercial payers have migrated their fee schedules to the 98000-series and may no longer pay 99443 claims. Others continue to recognise the legacy codes. Check the AAPC CPT code lookup for descriptor details, then verify coverage directly against each payer’s telehealth policy or provider bulletin before submitting claims.

Stop losing telephone E/M revenue to avoidable denials

Pabau routes CPT 99443 and audio-only telehealth claims through Claim.MD, validating code-payer combinations and flagging documentation gaps before submission. Book a demo to see how it works for your practice.

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Common reasons CPT 99443 claims are denied

Most CPT 99443 denials are preventable. The patterns below account for the majority of rejections seen in billing audits and coder community discussions across primary care, internal medicine, and psychiatry practices that bill telephone E/M regularly.

Solid denial management strategies start by tracking which denial reason code appears most frequently in your ERA files. Denial code CO-4 (procedure code inconsistent with the modifier) and CO-97 (payment bundled into another service) are the two most common for this code series. Routing claims through a clearinghouse claim validation step catches many of these before they reach the payer.

• New patient billed as established: The patient did not have a prior qualifying encounter within three years in the same group – the most frequent reason for a CO-4 or CO-5 denial on this code
• Call time not documented: The chart note records the call occurred but does not state the duration, or states a time under 21 minutes – insufficient to support 99443 over 99442
• Call led to a same-day or next-available visit: The telephone encounter is bundled into the pre-service work for the in-person or virtual visit and cannot be billed separately
• Incorrect or missing POS code: Submitting without POS 02 or POS 10 when the payer requires it for telehealth claims generates an automatic edit failure
• Missing or incorrect modifier: Payers requiring modifier 95 or GT will deny claims submitted without the appropriate modifier – or reject claims that include a modifier the payer does not recognise for audio-only services
• Payer does not cover audio-only: The payer’s telehealth benefit excludes audio-only encounters, or the code has been retired from their fee schedule in favour of the 98000-series
• Global period conflict: The call falls within a global surgical period for a procedure previously performed, bundling the telephone service into the post-operative care fee

Payer coverage beyond Medicare for CPT 99443

Commercial payers and state Medicaid programs do not follow a single standard for telephone E/M coverage. Some mirror CMS policy closely; others have maintained audio-only coverage that Medicare scaled back after the public health emergency. A practice billing 99443 to three different commercial payers may find all three have different coverage rules for the same code.

Verify each payer’s telehealth coverage bulletin or provider manual before billing. Key questions to confirm per payer: Does the payer accept 99443 or has it migrated to 98012-98014? Is prior authorisation required for audio-only telephone services? Does the payer require a specific modifier? Is POS 10 (patient’s home) accepted for audio-only, or only POS 02? Review the PGM Billing CPT lookup tool to cross-reference fee schedule data across payers. For state Medicaid, no blanket assumption applies – each state program sets its own audio-only telehealth coverage policy, and some states have maintained expansions post-PHE while others reverted. Confirm with the state Medicaid provider portal directly.

Can CPT 99443 be billed with other codes on the same day?

CPT code 99443 can be billed alongside certain other codes on the same date of service, but several bundling restrictions apply. The most important rule is the same-day visit exclusion: if the telephone call results in the patient being seen in person (or via a video visit) within 24 hours or the next available appointment, the telephone service is considered part of the pre-service work for that encounter and cannot be reported separately.

• Preventive codes (99381-99397): Billing a telephone E/M on the same date as a preventive visit is generally not supported unless a separate, distinctly documented problem was addressed on the call that is above and beyond the preventive service
• Same-day office or outpatient E/M (99202-99215): Cannot be billed with 99443 on the same date when the call directly preceded or led to the in-person visit
• Chronic care management (CCM) codes: Time spent on qualifying telephone calls may be counted toward CCM time thresholds (99490, 99491 series) depending on payer policy – but the same minutes cannot be claimed under both a CCM code and a telephone E/M code
• Smoking cessation counseling (99406): May be reported on the same date if the counseling was a distinct, separate service clearly documented as such; payer-specific NCCI edits apply

When in doubt on bundling, check the CMS NCCI (National Correct Coding Initiative) edit tables. The clean claim submission standard requires that any code combination submitted to a payer be free of NCCI column-one/column-two conflicts before the claim leaves the practice.

Conclusion

Telephone E/M billing under CPT 99443 trips up practices most often at three points: documenting call time precisely, confirming established-patient status before submitting, and checking whether the call triggered a same-day visit. None of these are complex – but each requires a consistent pre-submission workflow.

Pabau’s claims management software routes CPT 99443 and related audio-only telehealth claims through Claim.MD, applying payer-specific edits and code-pair validation before the claim reaches the insurer. To see how it handles telephone E/M billing for your practice, book a demo.

Continue your research

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