CPT 98972
Global XXX ActiveNqhp ol dig assmt&mgmt 21+
CPT 98972 Billing & Documentation Guide
CPT code 98972 (Nqhp ol dig assmt&mgmt 21+) is classified under Medicine/E&M with a global period indicator of XXX. The 2026 Medicare Physician Fee Schedule assigns a work RVU of 0.69, a non-facility practice expense RVU of 0.31, and a malpractice RVU of 0.03, a total non-facility RVU of 1.03 and facility RVU of 0.87. With the current conversion factor of $33.4009, the national average non-facility reimbursement is approximately $35.18, though rates vary from $32.46 to $46.15 based on MAC locality and Geographic Practice Cost Indices (GPCIs).
When billing 98972, ensure documentation supports medical necessity and the specific components required for the code's level of service. For E/M codes, document MDM (medical decision-making) elements: problems addressed, data reviewed, and risk. For procedural codes, document the indication, technique, and any complications. Always verify NCCI edits before bundling 98972 with related codes; this code has 10 PTP bundling relationships on file (see table below).
Payment Status & Global Period
Active code (paid under MPFS)
No global period (E/M and other non-procedural services)
MUE Limit (Medically Unlikely Edits)
Submitting more than 1 units of 98972 for the same patient on the same date triggers automatic line denial unless an appropriate modifier and supporting documentation justify the higher quantity.
RVU Breakdown, CPT 98972
| Component | Non-Facility | Facility |
|---|---|---|
| Work RVU | 0.69 | 0.69 |
| Practice Expense RVU | 0.31 | 0.15 |
| Malpractice RVU | 0.03 | 0.03 |
| Total RVU | 1.03 | 0.87 |
| Conversion Factor | $33.4009 | |
2026 Medicare Reimbursement by State, CPT 98972
State-level averages across all MAC localities. Non-facility rates typically apply to office-based services; facility rates apply to hospital outpatient / inpatient.
| State | Non-Facility | Facility | Range (Non-Fac) | Localities |
|---|---|---|---|---|
| California | $36.67 | $30.35 | $35.32 - $41.05 | 29 |
| Florida | $35.39 | $30.02 | $34.45 - $36.36 | 3 |
| Georgia | $34.16 | $29.06 | $33.48 - $34.84 | 2 |
| Illinois | $35.05 | $29.88 | $34.07 - $35.91 | 4 |
| Michigan | $34.18 | $29.16 | $33.63 - $34.73 | 2 |
| North Carolina | $33.35 | $28.36 | $33.35 - $33.35 | 1 |
| New York | $37.05 | $31.09 | $33.59 - $38.69 | 5 |
| Ohio | $33.51 | $28.63 | $33.51 - $33.51 | 1 |
| Pennsylvania | $34.47 | $29.23 | $33.5 - $35.44 | 2 |
| Texas | $34.3 | $29.04 | $33.4 - $34.94 | 8 |
Source: CMS PFSRVU 2026 · Updated 2026-04-01. Full locality-level detail available for all 53 states, contact us for custom reports.
NCCI Bundling Edits, CPT 98972
Procedure-to-procedure (PTP) edits. If you bill any of these codes with 98972 on the same date of service, review the modifier indicator and payer policy before submission.
| Partner Code | Relationship | Modifier Allowed | Rationale |
|---|---|---|---|
| 36591 | Column 1 (primary), can be billed with modifier | No | CPT Manual or CMS manual coding instruction |
| 36592 | Column 1 (primary), can be billed with modifier | No | CPT Manual or CMS manual coding instruction |
| 96523 | Column 1 (primary), can be billed with modifier | No | CPT Manual or CMS manual coding instruction |
| 99424 | Column 1 (primary), can be billed with modifier | Yes | CPT Manual or CMS manual coding instruction |
| 99425 | Column 1 (primary), can be billed with modifier | Yes | CPT Manual or CMS manual coding instruction |
| 99426 | Column 1 (primary), can be billed with modifier | Yes | CPT Manual or CMS manual coding instruction |
| 99427 | Column 1 (primary), can be billed with modifier | Yes | CPT Manual or CMS manual coding instruction |
| 99437 | Column 1 (primary), can be billed with modifier | Yes | CPT Manual or CMS manual coding instruction |
| 99489 | Column 1 (primary), can be billed with modifier | Yes | CPT Manual or CMS manual coding instruction |
| G0250 | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
Frequently Asked Questions, CPT 98972
What does CPT code 98972 mean? +
CPT code 98972 represents: Nqhp ol dig assmt&mgmt 21+. It's in the Medicine/E&M category with a global period of XXX.
What is the Medicare reimbursement for CPT 98972? +
The 2026 Medicare national average non-facility payment for CPT 98972 is $35.18. Rates range from $32.46 to $46.15 across 53 states depending on MAC locality and GPCIs.
What modifiers can I use with CPT 98972? +
Medicine section spans a wide range: therapy services use GP/GO/GN (PT/OT/SLP plans of care) and KX (above cap with documentation). Drug administration uses JW (waste) and JZ (no waste). Professional/technical split applies to some diagnostic codes.
What bundling edits apply to CPT 98972? +
This code has 10 NCCI PTP bundling relationships. See the NCCI Bundling section below for full list.
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Reviewed by the PayerReady Medical Coding Team
Verified against the CMS 2026 code set on June 2, 2026.
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