CPT® Code 98969

Deleted

1. Indications

The online assessment and management service represented by CPT® Code 98969 is indicated for established patients or their guardians who require a nonphysician health care professional's expertise. This service is appropriate when the patient has specific complaints or concerns that need to be addressed through electronic communication. It is particularly useful for patients who may not need an in-person visit but still require guidance, counseling, or modifications to their treatment plan. The service is not intended for situations where a related assessment and management service has been conducted within the previous seven days, ensuring that the online encounter is a distinct interaction.

• Established Patient The service is intended for patients who have previously received care from the provider.
• Guardian Involvement The service can also be initiated by a guardian on behalf of the patient.
• Non-Related Service The online encounter must not be related to any assessment and management service provided within the last seven days.

2. Procedure

The procedure for CPT® Code 98969 involves several key steps that ensure a comprehensive online assessment and management service is delivered effectively.

• Step 1: Initiation of Service The process begins when an established patient or their guardian initiates contact with the qualified nonphysician health care professional through an electronic communication platform. This could be via email or another similar method, allowing for a convenient and accessible means of communication.
• Step 2: Review of Concerns Once the communication is established, the health care professional reviews the patient's complaints and concerns as presented in the electronic message. This step is crucial for understanding the patient's needs and determining the appropriate course of action.
• Step 3: Information Gathering The professional may request additional information related to the patient's condition or concerns. This could involve asking specific questions to clarify the situation and gather necessary details that will inform the assessment.
• Step 4: Counseling and Instruction After reviewing the information, the qualified nonphysician health care professional provides counseling and instruction tailored to the patient's needs. This may include advice on managing symptoms, lifestyle modifications, or other relevant guidance.
• Step 5: Treatment Plan Modification If necessary, the professional may modify the existing treatment plan based on the assessment conducted during the online encounter. This ensures that the patient receives the most appropriate care based on their current situation.
• Step 6: Documentation Finally, the entire interaction, including the assessment, counseling provided, and any modifications to the treatment plan, must be documented in the patient's medical record. This documentation is essential for maintaining accurate health records and ensuring continuity of care.

3. Post-Procedure

After the online assessment and management service is completed, the patient or guardian may be advised on any follow-up actions or additional steps that may be necessary. This could include scheduling an in-person visit if further evaluation is required or implementing the recommendations provided during the online encounter. The qualified nonphysician health care professional should ensure that the patient understands the next steps and has access to any resources or support needed to manage their condition effectively. Additionally, the documentation of the service in the medical record serves as a reference for future encounters and continuity of care.