Internal Medicine Coding Alert

Also, beneficiaries with diabetes, becoming newly eligible for Medicare, can receive diabetes outpatient self-management training in this program, according to CMS program memorandum B-01-40.

"Diabetes outpatient self-management services may be covered by Medicare only if the physician or qualified nonphysician practitioner who is managing the beneficiary's diabetic condition certifies that such services are needed by sending an original referral form to the diabetes education program," says Bruce Rappoport, MD, CPC, a board-certified internist who works with physicians on compliance, documentation, coding and quality issues for RCH Healthcare Advisors LLC, a Fort Lauderdale, Fla.-based healthcare consulting company.

The referral for education must be done under a comprehensive plan of care related to the beneficiary's diabetic condition to ensure therapy compliance or to provide the individual with necessary skills and knowledge (including skills related to the self-administration of injectable drugs) in the management of the beneficiary's conditions, he adds. Rappoport directs coders to the specific provider requirements that are addressed below and can be found at 42 CFR 410.140-146.

All certified providers who provide other individual items or services on a fee-for-service basis and meet quality standards can receive reimbursement for diabetes training. (As with all fee-for-service benefits, M+COs may only be reimbursed for diabetes outpatient self-management training if they meet all the requirements and are billing for services provided to beneficiaries not enrolled in a Medicare+Choice plan.) Certified providers must be currently receiving payment for other Medicare services.

As for the outpatient diabetes self-management training program requirements, the program must be accredited as meeting approved quality standards, except during the first 18 months after Feb. 27, 2001.

When an internist not an ADA-certified provider provides diabetes education during patient office visits, there are different rules and coding guidelines for reporting the educational services.

When an internist sees a patient for follow-up for diabetes and the physician him- or herself provides diabetes education during that office visit, if greater than 50 percent of that session is spent educating that patient one-on-one within the office, the internist should document the appropriate evaluation and management codes based on time, Falbo instructs coders.

For example, an internist sees a new patient who has new onset diabetes, and the physician performs the required history, physician exam and medical decision-making component of a new patient office visit. Then the internist turns to counseling the patient on managing her diabetes, documenting the content of the counseling session, i.e., documentation of reviewing an acceptable diet, minimalization of carbohydrate intake, exercise-routine suggestions, etc. The internist reports spending 30 minutes with the patient, 17 minutes of which were spent discussing the diabetes management recommendations. The 17 minutes of counseling constitute greater than 50 percent of the exam, so the internist can bill the visit based on time, Falbo says.

When ADA-certified diabetes self-management training providers give educational services, how you report their services will depend on whether the patient is covered by Medicare or by a third-party payer.

According to CMS, a "certified provider" is "a physician or other individual or entity designated by the Secretary that, in addition to providing diabetes outpatient self-management services, provides other items or services for which payments may be made such as medical services or durable medical equipment, and meets certain quality standards." But eligible providers are not limited to physicians, durable medical equipment suppliers, renal dialysis facilities and hospital outpatient departments, thanks to Program Memorandum B-01-40, Rappoport says. If, for example, a nurse has received a "certificate of recognition" from the ADA, the nurse's training services could be billed, he adds.

According to the transmittal, individuals, such as nurses, who have received certificates of recognition from the ADA indicating they meet the National Standards for Diabetes Self-Management Training Programs are also considered eligible providers.

If the patient is covered by Medicare and meets Medicare's required medical indications and the individual providing the diabetes education is a certified provider, you can bill for the self-management training with G0108 (Diabetes outpatient self-management training services, individual, per 30 minutes) and G0109 (Diabetes self-management training services, group session [2 or more], per 30 minutes).

Some carriers will cover code 99078 (Physician educational services rendered to patients in a group setting [e.g., prenatal, obesity, or diabetic instructions]) for providing education when the program is noncertified. And if the patient is covered by a commercial carrier and the diabetes self-management training is being rendered in a group setting, you should report CPT code 99078.

Remember, the training must be ordered by the physician or qualified provider who is treating the beneficiary's diabetes, and the order must be part of a comprehensive plan of care. The transmittal also instructs providers to "include a statement signed by the physician" that indicates the service is needed.

For more information regarding the requirements for initial and follow-up sessions of outpatient diabetes self-management training, see CMS program memorandum B-01-40 available on the CMS Web site at www.cms.gov.

One source of confusion for internal medicine practices when reporting diabetes education services is the different requirements for reporting medical nutrition therapy for Medicare patients, Falbo says.

Medical nutrition therapy (MNT) zeroes in on how nutritional adjustments play a role in managing patients who have diabetes or renal disease that does not require dialysis the key qualifier for Medicare, Falbo says. Unlike diabetes self-management training, of which Medicare patients can receive a maximum of 10 hours per year, Medicare patients can receive up to three hours of MNT for the first year, and they are eligible for two additional hours in subsequent years with a referral from the treating physician.

Also, referrals for MNT can only be made by the treating physician and cannot be made by a nonphysician practitioner, Rappoport adds, "And a patient cannot receive DSM and MNT on the same day."

And unlike diabetes self-management training, "physicians cannot bill Medicare for MNT services," Falbo emphasizes. "This is only for registered dietitians and nutrition professionals," another key difference from diabetes self-management training, which had different requirements for "certified providers."

These registered dietitians and nutrition professionals should bill under their own UPIN numbers, she says, and they can expect to be reimbursed 85 percent of the fee allotted in the Medicare Physician Fee Schedule Database for individual MNT code G0270 (Medical nutrition therapy, reassessment and subsequent intervention[s] following second referral in same year for change in diagnosis, medical condition or treatment regimen [including additional hours needed for renal disease], individual, face to face with the patient, each 15 minutes) and group MNT code G0271 (Medical nutrition therapy, reassessment and subsequent intervention[s] following second referral in same year for change in diagnosis, medical condition, or treatment regimen [including additional hours needed for renal disease], group [2 or more individuals], each 30 minutes).