Internal Medicine Coding Alert

Diabetes is a major health concern, particularly to Medicare beneficiaries. The American Diabetes Association estimates that 15.7 million Americans have diabetes and 18.4 percent of the U.S. population age 65 and older is affected by the disease. To better serve the estimated 798,000 individuals who will be diagnosed with diabetes this year, some internal medicine practices have added certified diabetes educators and dietitians to their staff. Getting reimbursement from Medicare for the services of these non-physician providers will be difficult, however, if the practice is not a recognized diabetes education provider.

Diabetes education programs instruct patients in the successful self-management of the disease. The programs include instruction about self-monitoring of blood glucose, using diet and exercise in controlling the condition, and following an insulin treatment plan developed for the patient. The program also tries to motivate patients to use self-management techniques taught in the classes.

Medicare Covers Certified Education Programs

In July 1998, Medicare initiated a policy of providing reimbursement for diabetic education programs recognized by the American Diabetes Association. Up to 10 hours of instruction are covered for the initial training, and additional instruction may be covered if the patient experiences a significant change in his or her condition, such as going from a non-insulin to insulin-based treatment.

Medicare also has set up two HCPCS codes to report these services. Code G0108 (diabetes outpatient self-management training services, individual session, per 60 minutes) is used to report individual instruction sessions. Reimbursement for these individual sessions will be approximately $60 an hour, according to David Holtzman, director of government affairs for the American Association of Diabetes Educators in Chicago. Code G0109 (diabetes outpatient self-management training session, group session, per 60 minutes) is used to report the more common group instruction sessions. Reimbursement for these sessions will be approximately $35 an hour, says Holtzman.

Although the coding for Medicares diabetes education program is fairly straightforward and easy to understand, there are several coverage and payment stipulations set forth by the program that have discouraged participation by internal medicine practitioners.

Medicare Doesnt Reimburse All Educators

The main requirement of Medicares reimbursement policy is that the diabetes education is provided through a program certified by the American Diabetes Associations Education Recognition Program (ADA-ERP). The certification, which is based on standards identified by the National Diabetes Advisory Board, requires a program to have on staff both a registered nurse and registered dietitian, according to Lynn Moseley, RD, associate director of the Education Recognition Program for the Alexandria, Va.-based American Diabetes Association. The application process requires an applicant to collect six months of data on its current diabetes patients, measure clinical outcomes and assess its patients knowledge of diabetes self-management. After the data has been compiled, the application and programs curriculum are subject to a peer review by experts in the field of diabetes management and instruction.

Until the Medicare ruling came out, most of the ERP certificates were going to hospitals and other medical institutions, says Moseley. But since the new Medicare policy went into effect, she has noticed an increase in applications from medical practices. And she confirms
that Medicare really does call us to see who has a recognized program.

In addition to having a certification, Medicare also has the following coverage and payment requirements that must be met:

ERP certificates must be on file with the local Medicare payer before a claim for diabetes education is submitted. (HCFA transmittal no. AB-98-51, Sept. 1998)

The education sessions should be billed only in one- hour increments without any rounding up or down. If the training session lasts more than one hour, the extra time can be counted toward future sessions. (HCFA transmittal no. AB-98-51, Sept. 1998)

Certified diabetic educators (CDEs), dietitians and physician assistants that are employed by providers or entities that have an ADA-ERP may give diabetes education. But reimbursement may be made only to their employer under the incident to rules because they are not certified providers themselves. (HCFA transmittal no. AB-98-36, July 1998; and transmittal no. AB-98-51, Sept. 1998)

Nurse practitioners and clinical nurse specialists who work with a provider or entity that has an ADA-ERP may bill Medicare Part B directly for the services performed in collaboration with a physician. (HCFA transmittal no. AB-98-36, July 1998)

Because of Medicares ADA-ERP requirement, there are many diabetes educators whose services are not eligible for reimbursement. Holtzman estimates that there are approximately 750 ADA-ERP programs in the country, while there are more than10,000 CDEs, who usually are registered nurses. There are also registered nurses and registered dietitians who do not have a CDE, but also provide diabetes education.

Bill the Patient Directly for Educational Services

Many internal medicine practices that do not have an ADA-ERP are attempting to capture revenue for the services these non-physician providers perform. One solution is to bill the patient directly for any education services rendered solely by a registered nurse or dietitian. When the diabetes educator at the Long Street Clinic, a multispecialty practice with four internists in Gainesville, Ga., provides nutritional counseling or other types of patient education, the patient is billed directly, according to Jeannie McGahee, CPC, MTASCP, case manager for the practice.

We bill the patient directly because we arent Medicare approved, and even private insurance companies frequently wont cover these sessions, she explains. They want the patient to come to a class held at a hospital or facility of their choice.

E/M Visits Only Cover Physician Time

Some internal medicine practices would like to bill the educational services provided by a registered nurse or dietitian as part of an office visit where time spent counseling and coordinating care becomes the key to qualifying for a particular level of evaluation and management (E/M) service. Typically, these are joint visits where the internist first sees the patient to outline a course of treatment. The internist will then turn the patient over to the nurse, who instructs the patient on specific topics such as how to monitor his or her blood sugar or how to inject insulin.

It is not appropriate, however, to include the time spent by the nurse or dietitian with the patient when determining the evaluation and management (E/M) service level, according to Barbara J. Cobuzzi, MBA, CPC, CHBME, president of Cash Flow Solutions Inc., a physician billing and consulting service in Lakewood, N.J. The CPT definitions for E/M services clearly state that it is only the physicians face-to-face time with the patient that matters. There is no good way to bill Medicare for the services of a registered nurse and a dietitian.

If the patient comes in just to see the registered nurse, then that visit can be reported with 99211 (office or other outpatient visit), says Susan Calloway-Stradley, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C. That visit cannot occur on the same day as a visit with the internist, she adds. If it does, the nurse visit will be bundled into the internists E/M service.

Although many coding experts say they have heard of places that were aggressively coding E/M visits to include time spent by only the nurse with the patient, they cautioned internists against adopting that practice.

I suspect that as the carriers become more aware of Medicares policies and procedures for the diabetes education benefit, they will more closely scrutinize claims filed for the services, explains Holtzman.

Bill Secondary Insurance Payers

Another reimbursement option for internal medicine practices would be to bill the secondary insurance payers of Medicare beneficiaries, many of which are required by state law to provide coverage of diabetes education, notes Holtzman. The claim must be filed first with Medicare. Upon receiving a denial from the Medicare carrier, the claim then can be routed to a secondary payer for consideration.

Holtzman also believes there may be significant changes in Medicares policy before the end of the year. The current policy is a temporary one set down only in program memorandums, he explains. His organization, along with several others, is lobbying for an expansion of Medicares definition of who is a certified diabetes educator.