CPT Codes for Digital E/M Service

In the 2020 CPT codes set, CMS six released new codes to report online digital evaluation services or e-visits. The codes describe patient-initiated digital communications provided by physicians or other qualified health professionals, codes are 99421, 99422, and 99423. Three others who describe similar interactions when they involve a nonphysician health professional are 98970, 98971, and 98972. The new codes are spurred by digital health tools that are growing in popularity, such as patient portals. These tools enable patients and physicians to connect asynchronously and outside of face-to-face settings, making it easier for patients with transportation and scheduling barriers to get questions answered and receive care.

These six new codes will help physicians and others report a range of digital health services including electronic visits through secure patient portal messages. Digital evaluation and management services are not considered as telehealth services, so do not use POS 02 and modifier 95. CMS is requiring verbal consent for communication-based technology services (CBTS). This verbal consent is required annually and encompasses all CBTS, not a consent/service or consent for each provision of the service. 

CPT Codes for Digital E/M Service

For Qualified Health Professionals (QHP)

  • CPT Code 99421: Online digital evaluation and management (E/M) service, for an established patient, for up to 7 days cumulative time during the 7 days; 5-10 minutes
  • CPT Code 99422: 11-20 minutes
  • CPT Code 99423: 21 or more minutes

Above mentioned codes are for use when E/M services are performed, of a type that would be done face-to-face, through a HIPAA compliant secure platform. These are for patient-initiated communications and may be billed by clinicians who may independently bill an E/M service. They may not be used for work done by clinical staff or for clinicians who do not have E/M services in their scope of practice.

Defining 7-day period: The seven-day period begins with the physician’s or other qualified health care professional’s (QHP) initial, personal review of the patient-generated inquiry. Physician’s or other QHP’s cumulative service time includes a review of the initial inquiry, review of patient records or data pertinent to assessment of the patient’s problem, personal physician or other QHP interaction with clinical staff focused on the patient’s problem, development of management plans, including a physician or other QHP generation of prescriptions or ordering of tests, and subsequent communication with the patient through online, telephone, email, or other digitally supported communication, which does not otherwise represent separately reported E/M service.

Coding Guidelines

  • Codes are applicable only for established patients.
  • As mentioned above, verbal consent is required by CMS. This verbal consent is required annually and encompasses all CBTS, not a consent/service or consent for each provision of the service.
  • The patient initiates the service with an inquiry through the portal. 
  • If the patient had an E/M service within the last seven days, these codes may not be used for that problem. If the inquiry is about a new problem (from the problem addressed at the E/M service in the past 7 days), these codes may be billed.
  • If within seven days of the initiation of the online service a face-to-face E/M service occurs, then the time of the online service or decision-making complexity may be used to select the E/M service, but this service may not be billed.
  • This may not be billed by surgeons during the global period.
  • The digital service must be provided via a HIPAA compliant platform, such as an electronic health record portal, secure email, or other digital applications.

For Qualified Nonphysician Health Care Professionals

For online digital E/M services provided by a qualified nonphysician health care professional who may not report the physician or other qualified health care professional E/M services (e.g., speech-language pathologists, physical therapists, occupational therapists, social workers, dietitians), applicable codes are 98970, 98971, and 98972. CMS, however, said in the 2020 Final Rule that they would not recognize these codes, because they are defined by CPT as ‘evaluation and management services, and CMS reserves those words exclusively for physicians, advance practice nurse practitioners, and physician assistants. These codes have a status indicator of invalid in the Medicare fee schedule and don’t have RVUs assigned to them.

  • CPT Code 98970: Qualified nonphysician health care professional online digital evaluation and management service, for an established patient, for up to 7 days, a cumulative time during the 7 days; 5-10 minutes. 
  • CPT Code 98971: 11-20 minutes
  • CPT Code 98972: 21 minutes or more

*CPT is a registered trademark of the American Medical Association (AMA) Copyright 2022

MedicalBillersandCoders (MBC) is a leading medical billing company providing complete revenue cycle services. Most providers make the mistake of billing digital E/M services as telehealth services, and end up with denied payments. We can help you in each process of outsourcing medical billing to ensure that you will receive accurate insurance reimbursements. To know more about our medical billing services, contact us at info@medicalbillersandcoders.com/ 888-357-3226

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