CPT 98960 Billing Guide 2025 - Patient Education & Self-Management Training

CPT code 98960 allows physical therapy clinics to bill for patient education and training services, yet 67% of PT practices report confusion about proper documentation and reimbursement protocols. With recent 2025 CMS updates affecting patient education CPT code billing, understanding these requirements is critical for avoiding denials and maximizing revenue.

This comprehensive guide addresses the most common 98960 CPT code billing challenges, provides specific reimbursement strategies, and ensures your practice maintains compliance with current healthcare regulations.

CPT Codes Applicable to Patient Education

When it comes to patient education CPT Codes in physical therapy it’s important to note that there isn’t a specific code designated solely for patient education. Instead, you’ll need to choose codes based on the nature of the service or physical therapy you provide. 

For patient education related to specific therapeutic activities, you can use relevant CPT codes like:

• CPT 98960: This code is used for billing patient education and training provided by a non-physician healthcare professional. It covers face-to-face, one-on-one sessions lasting 30 minutes, focused on teaching patients or caretakers how to manage chronic conditions like Hypertension, diabetes, asthma, or COPD, improving self-care and health outcomes at home.
  
  
• CPT 97110: This code applies when you provide therapeutic exercises aimed at increasing strength, endurance, or flexibility. For example, if you’re teaching patients exercises to improve their functional strength.
  
  
• CPT 97530: Use this code for therapeutic activities focused on improving functional performance. It would also be applicable if you were educating the patient on how to integrate these exercises into their daily routine.

These codes not only document the exercise or activity but also cover the educational aspect since patient instruction is inherent to these therapeutic services.

Watch this video on YouTube that talks about  2024 Remote Patient Monitioring: CPT Codes, Billing and Reimbursements, 

This video is nicely explained by Care Coordination Software by ThouroughCare on their channel and covers everything that you need to know about RPM CPT Codes as of 2024. 

What Is CPT Code 98960 and When Should You Use It?

CPT 98960 is designated for "education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient."

98960 CPT Code Description Breakdown:

• Duration: Each unit represents 30 minutes of direct patient education
• Provider: Must be delivered by qualified nonphysician healthcare professional
• Format: Face-to-face interaction (includes telehealth when compliant)
• Content: Standardized curriculum for self-management education
• Participants: Individual patient (caregiver/family may be included)

The CPT code for patient education is particularly valuable for chronic condition management, post-surgical recovery education, and preventive care instruction in physical therapy settings.

Code Specifics for Individual and Group Sessions in Self-Management

For sessions focusing on self-management education, particularly when patients are learning how to manage chronic conditions, there are additional codes:

• CPT 98960: This code also applies to individual self-management training provided by an NPP (Non-Physician Practioner), typically billed in 30-minute increments. If you’re guiding a patient on managing their condition (e.g., diabetes or asthma), this would be relevant.
• CPT 99078: This code is specifically for group education sessions, where you might educate multiple patients simultaneously on managing their health conditions in a group session or a workshop. 

Suggested Read: Understanding Billing Units in Physical Therapy: A Guide to the 8-Minute Rule.

By selecting the correct CPT code, you ensure your patient education efforts are accurately documented and billed. Now, let's explore effective Billing Strategies for Patient Education to ensure proper reimbursement for your clinic. 

Billing Strategies for Patient Education

Billing Strategies for Patient Education are crucial to ensure accurate reimbursement for services provided. Here’s how you can approach it:

1. Use CPT Codes that Align with your Therapy or Services Provided: Relevant CPT codes like 97110 (therapeutic exercises) or 97112 (neuromuscular re-education) can be used to bill for educational services during therapy.
2. Accuracy in Medical Coding and Billing Practices: Accurate coding ensures appropriate reimbursement, minimizes claim rejections, and reduces the risk of audits by verifying your patient’s insurance. You might like reading about the Process of Verifying Patient Health Insurance. 
3. Billing Codes Based on Intent: Choose codes like 97112 for balance and coordination education or 97530 for functional activity training, reflecting the session's therapeutic intent.
4. Documenting Time-Based Education Sessions: Use time-based CPT codes (e.g., CPT 98960) for self-management education, ensuring documentation of time spent and patient participation.
5. Maximizing Reimbursement for Group Education: When conducting group sessions, use codes like CPT 99078, which covers patient education for groups, ensuring all services are billed efficiently.
6. Improving Remote Therapeutic Monitoring (RTM) Codes: For virtual patient education or remote monitoring, use CPT 98975-98977 for remote therapeutic monitoring, ensuring compliance with telehealth billing standards.

These strategies help ensure comprehensive billing for patient education while maintaining accuracy and maximizing reimbursement opportunities. 

Platforms like SPRY PT streamline billing for PT clinics with automated workflows, real-time eligibility checks, and error reduction. They also enhance accuracy and speed up reimbursements, making them the ideal solution for maximizing clinic revenue. Talk to SPRY here! 

Now, let’s discuss Case Management in Physical Therapy and its critical role in enhancing patient care.

How Do You Avoid Common CPT 98960 Billing Denials?

98960 CPT billing denials often result from preventable documentation and coding errors. Understanding common denial patterns helps practices implement proactive compliance measures.

Top 5 Denial Reasons and Solutions:

1. Lack of Medical Necessity

• Problem: Education not clearly linked to medical condition
• Solution: Document specific medical conditions requiring self-management education
• Prevention: Obtain detailed physician orders specifying educational needs

2. Insufficient Time Documentation

• Problem: Missing or inaccurate time reporting
• Solution: Use precise time tracking for each 30-minute increment
• Prevention: Implement electronic time tracking systems

3. Non-Standardized Curriculum

• Problem: Ad-hoc educational content without structured curriculum
• Solution: Develop evidence-based educational protocols
• Prevention: Create standardized curriculum materials with measurable objectives

4. Provider Qualification Issues

• Problem: Services provided by unqualified personnel
• Solution: Ensure all providers meet payer-specific qualification requirements
• Prevention: Maintain current credentialing and training documentation

5. Duplicate Service Billing

• Problem: Billing education services already included in other therapy codes
• Solution: Clearly differentiate education-only services from therapeutic interventions
• Prevention: Implement billing edits to prevent duplicate submissions

Denial Prevention Checklist:

• ✓ Verify patient eligibility and benefits before service
• ✓ Obtain required physician orders with medical necessity
• ✓ Use standardized curriculum with measurable outcomes
• ✓ Document exact time spent in face-to-face education
• ✓ Ensure provider meets qualification requirements
• ✓ Submit claims with complete supporting documentation

Billing Documentation for Education and Case Management

Proper documentation is important to ensure accurate billing and compliance with regulations. It also justifies the medical necessity of the services provided, ultimately protecting your practice and ensuring timely reimbursements. The basic requirements for documentation are mentioned below. 

1. Patient Demographic Information: Includes personal details like name, address, date of birth, and insurance information.
2. Medical History and Assessment Records: Documentation of the patient's health status, diagnoses, and care plans.
3. Physician’s Orders or Referrals: Written documentation from a physician outlining the required services or referrals for case management.
4. Treatment Notes and Progress Reports: Detailed notes of the services provided, patient progress, and any changes to the treatment plan.
5. Service Authorization Forms: Written authorization from the insurance provider or payer confirming coverage for the services rendered.
6. Encounter Forms or Superbills: Itemized forms detailing the services and treatments provided, including relevant codes for billing (CPT, ICD-10). You might like reading about What is a Superbill and How does it work in Medical Billing?
7. Educational Material Provided to the Patient: Documentation of any education offered to the patient regarding their care, treatment, or condition.
8. Case Management Documentation: Records outlining case management activities, including coordination of care and any follow-up.
9. Consent Forms: Signed patient consent forms for the treatments and services provided.
10. Explanation of Benefits (EOB): A document provided by the payer explaining what was billed, paid, or denied.
11. Insurance Pre-authorization or Prior Approval: Proof of any required pre-authorizations obtained from the insurer before providing services.
12. Billing Records and Invoices: Records of submitted claims and invoices for reimbursement. 

These documents ensure accuracy and compliance while justifying the medical necessity of services rendered for education and case management purposes.

Watch this video on YouTube about the CPT Coding Guidelines on Case Management Services.

This video is explained by Sai Shruthi on her channel, where she focuses on providing resourceful videos on medical coding. 

What Are the Best Practices for CPT 98960 Implementation?

Successful CPT code 98960 implementation requires systematic approach to curriculum development, staff training, and quality assurance. These practices maximize both patient outcomes and reimbursement success.

Curriculum Development Standards:

• Evidence-based content: Use peer-reviewed research and clinical guidelines
• Measurable objectives: Establish clear learning goals with assessment criteria
• Standardized delivery: Ensure consistent content across all providers
• Outcome tracking: Implement systems to measure educational effectiveness
• Regular updates: Revise curriculum based on current best practices

Staff Training Requirements:

• Initial certification: Comprehensive training in educational delivery methods
• Ongoing education: Regular updates on billing and compliance requirements
• Competency assessment: Periodic evaluation of teaching effectiveness
• Documentation training: Specific instruction on required record-keeping
• Quality assurance: Regular auditing of services and documentation

Technology Integration:

• EMR optimization: Configure systems for efficient CPT 98960 documentation
• Time tracking: Implement accurate time measurement tools
• Outcome measurement: Use digital tools to track patient progress
• Billing automation: Integrate coding and billing workflows
• Compliance monitoring: Automated alerts for documentation requirements

How Does 98960 CPT Code Reimbursement Work in 2025?

98960 CPT code reimbursement varies significantly by payer and geographic location, with Medicare typically setting the baseline for other insurers. Understanding these rates is essential for revenue forecasting and billing optimization.

What Changes Are Expected for CPT 98960 in 2026?

Industry trends and regulatory developments suggest several potential changes to 98960 CPT code billing and coverage that practices should monitor for strategic planning.

Anticipated Modifications:

• Telehealth expansion: Permanent coverage for remote patient education services
• Value-based integration: Increased emphasis on patient outcome measurements
• AI-assisted education: Guidelines for technology-enhanced educational delivery
• Expanded provider types: Potential inclusion of additional qualified professionals
• Bundled payment integration: Incorporation into episode-based care models

Preparation Strategies:

• Technology investment: Upgrade systems for enhanced telehealth capabilities
• Outcome tracking: Implement robust patient outcome measurement systems
• Staff development: Prepare team for expanded educational service delivery
• Compliance monitoring: Stay current with evolving regulatory requirements
• Quality improvement: Focus on measurable educational effectiveness

How does SPRY PT Help?

SPRY PT simplifies this process by offering EMR/EHRs, automating billing workflows, integrating CPT codes, and offering real-time error checks, ensuring that your patient education and case management efforts are properly documented and billed. It streamlines clinic operations, maximizing efficiency and revenue for PT clinics. Check out the Pricing here!

Conclusion

In conclusion, managing billing for patient education and case management in physical therapy requires careful documentation and overcoming various challenges. With solutions like SPRY PT, you can streamline these processes, reduce errors, and ensure accurate reimbursement. 

By automating workflows and integrating compliance, SPRY PT enables you to focus on delivering high-quality patient care while optimizing clinic efficiency and revenue generation. Book a Free Demo here!