Does CPT Code 99443 Require a Modifier?

CPT codes serve as a standardized language for medical services and procedures, playing a role in healthcare billing and communication. They ensure consistent reporting for accurate claims processing and reimbursement. This article will focus specifically on CPT code 99443, detailing its definition, the nuances of modifier application, and the necessary documentation to support its use.

Defining CPT Code 99443

CPT code 99443 represents a telephone evaluation and management (E/M) service provided by a physician or other qualified healthcare professional. This code is specifically for medical discussions lasting 21 to 30 minutes. It applies when the service does not originate from a related E/M service within the past seven days and does not lead to an in-person E/M service or procedure within the next 24 hours or the soonest available appointment.

This code is time-based, with duration being the primary factor. It is intended for established patients, parents, or guardians. The service must involve detailed review and medical decision-making.

Modifier Application for CPT Code 99443

CPT code 99443 does not inherently require a modifier. However, specific modifiers may be used depending on the payer and the circumstances of the service. For instance, during the Public Health Emergency (PHE), Medicare allowed modifier -95 (Synchronous telemedicine service) with 99443 for higher reimbursement. This was a temporary flexibility, and as of 2024, Medicare generally no longer requires modifier -95 for audio-only services.

For audio-only services, modifier -93 (Synchronous telemedicine service via telephone) was introduced and became required by many commercial payers as of January 1, 2023. While CPT codes 99441-99443 are scheduled for deletion effective January 1, 2025, and new audio-only codes have been introduced, Medicare did not adopt these new codes. Providers must always check with individual payers, as their policies on modifier usage for telehealth services vary significantly.

Essential Documentation for CPT Code 99443

Documentation is essential to support billing CPT code 99443. The medical record must indicate the start and end times of the discussion, or total time spent. A detailed description of services provided is also necessary.

Documentation should justify the medical necessity for the telephone service, explaining why an in-person visit was not conducted and why the telephone interaction was sufficient and medically appropriate. The record should also identify any linked primary evaluation and management service, ensuring it does not overlap with other recent services.