99442

Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion

CPT code 99442 represents a telephone evaluation and management (E/M) service provided by a physician or other qualified healthcare professional (QHP) to an established patient, parent, or guardian. This specific code is designated for encounters where the medical discussion lasts between 11 and 20 minutes. The service is strictly non-face-to-face and relies exclusively on audio-only telecommunication. To appropriately report this code, several strict temporal and relational criteria must be met. First, the patient must be an established patient to the practice, meaning they have received professional services from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice within the past three years. Second, the telephone service cannot originate from a related E/M service that was provided within the previous seven days. If the telephone call is essentially a continuation or follow-up of a recent encounter, the time or work is considered bundled into that previous E/M service and cannot be reported separately. Furthermore, the telephone encounter must not lead to an E/M service or procedure within the next 24 hours or at the soonest available appointment. If the physician determines during the call that the patient needs to be seen urgently and schedules an appointment for the next day, the telephone service is not billed; rather, the time and complexity of the call are incorporated into the pre-encounter work of the subsequent face-to-face visit. During the call, the provider typically obtains a history, assesses the patient's clinical status, answers medical questions, reviews recent diagnostic test results, provides counseling or education, and establishes or modifies a treatment plan. Documentation must clearly record the medical necessity of the call, the identity of the person spoken to, the length of the medical discussion, the clinical details exchanged, and the resulting management plan. This code is particularly valuable for managing chronic conditions, addressing new acute but non-emergent symptoms, and providing timely medical guidance that prevents unnecessary emergency department visits while maintaining continuity of care.

Clinical Indications

  • Established patient requiring medical assessment or management via an audio-only telephone call.
  • Follow-up on newly prescribed medications requiring dosage adjustments or side-effect management.
  • Discussion of complex laboratory or imaging results that require an immediate change in the medical management plan.
  • Assessment of new, acute symptoms (e.g., mild dyspnea, isolated fever, localized rash) to determine if an in-person visit is medically necessary.
  • Chronic disease management and exacerbation triage (e.g., asthma, type 2 diabetes mellitus, essential hypertension) preventing an unnecessary emergency room visit.
  • Patient, parent, or guardian initiated call for medical advice requiring exactly 11 to 20 minutes of active physician or QHP medical discussion.

Procedure Steps

  1. Patient, parent, or guardian initiates the telephone call to the physician or qualified healthcare professional.
  2. Verify patient identity and confirm established patient status within the provider's practice.
  3. Obtain a detailed history of the present illness, symptoms, or specific medical reason for the call.
  4. Perform a clinical assessment based solely on the reported symptoms and the patient's historical medical data.
  5. Review relevant electronic medical records, prior laboratory results, or recent imaging reports as necessary during the discussion.
  6. Formulate a medical decision or treatment plan, which may include prescribing new medication, modifying existing medication orders, or recommending conservative home care.
  7. Provide counseling and education to the patient, parent, or guardian regarding the management plan and expected clinical course.
  8. Determine if an in-person follow-up is required, ensuring it does not occur within the next 24 hours or soonest available appointment to allow for separate billing.
  9. Document the total time of the medical discussion (must be 11-20 minutes), clinical details, and confirm criteria regarding prior (7 days) and future (24 hours) E/M visits are met.

Coding Guidelines

  • Do not report 99442 if the telephone call originates from a related E/M service provided within the previous 7 days. It is considered part of the previous service.
  • Do not report 99442 if the call leads to an E/M service or procedure within the next 24 hours or the soonest available appointment. In such cases, the call is considered pre-visit work.
  • Reportable only by physicians or qualified healthcare professionals who are licensed to report E/M services (e.g., MD, DO, NP, PA).
  • For non-physician professionals who cannot report E/M services (e.g., physical therapists, dietitians, social workers), use codes 98966-98968 instead.
  • The medical discussion time must be explicitly documented in the medical record, demonstrating exactly 11 to 20 minutes of time spent communicating with the patient, parent, or guardian.
  • The call must be initiated by the established patient, parent, or guardian.
  • May be subject to specific telehealth modifiers (e.g., modifier 95, modifier FQ) or place of service codes (e.g., POS 02 or 10) depending on the specific payer's current telemedicine and audio-only policies.
  • Do not count time spent performing administrative tasks or chart review prior to or after the call; only the actual discussion time counts toward the 11-20 minutes.

Associated ICD-10 Codes