Internal Medicine Coding Alert

Internal medicine practices with a large diabetic-patient population have been eagerly awaiting news on Medicares coverage of diabetes self-management education services (education about self-monitoring of blood glucose, diet and exercise, and development of insulin treatment programs).

However, stringent program and process standards imposed by the Health Care Financing Administration when it released coverage requirements for the new codes may put this option out of reach of many internal medicine practices.

As of July 1, 1998, practices have been authorized to use new HCPCS codes, G0108 (diabetes outpatient self-management training services, individual session, per 60 minutes of training) and G0109 (diabetes outpatient self-management training services, group session, per individual, 60 minutes of training), for diabetes self-management education. These codes carry Medicare allowables of $55.41 per hour and $12.62 per hour per beneficiary, respectively.

Note: These amounts are not adjusted for geographic locality. Contact your local Medicare carrier for more information.

Currently, many internal medicine practices are having a nurse, dietitian, or other non-physician provider perform the service, then billing for an office visit using 99211 (office or outpatient visit that may not require the presence of a physician). But, this code often does not yield enough reimbursement to cover the cost of the care delivered. In some cases, individual payers have been willing to cover these services using unlisted codes (codes that are recognized by the individual payer for this service). However, this practice is not widespread.

All Blue Cross-Blue Shield carriers in North Carolina have diabetes education reimbursement in place, says Alice Robinson, RRA, a reimbursement specialist with Physicians East, P.A., a large multi-specialty practice in Greenville, NC. But with Medicare, if the physician doesnt see the patient that day, we are left with billing 99211. We were really hoping this would come along and help us out.

Yet, due to HCFAs program requirements, many practice managers are still seeking out other options and waiting to whether HCFA will revise the standards.

Baptist Health Centers, Inc., a practice management group that runs approximately 70 clinics in the Birmingham, AL, area, probably will not use the new codes under the current stipulations, says Carol Ethridge, CPC, a coding specialist in Baptists corporate office.

I believe only the larger facilities will be setting up diabetes education programs, she states. None of our practices, which include internal medicine, have any plans to implement this program.

Were not billing for it separately here, concurs James Stephenson, CPC, reimbursement specialist in general internal medicine at the Cleveland Clinic Foundation in Cleveland, OH. We are waiting and kind of trying to let everything settle. Usually, when they (HCFA) implement something new, it takes about a year to work out the kinks.

Even Robinsons facility will probably not be able to use the new codes, she says. We are not an ADA [American Diabetes Association] certified program, she states. They have not decided whether they can go to the expense and effort of establishing a certified program.

Practice managers and experts contacted for this article presented several different options for billing diabetes self-management education services if a practice cannot meet the program requirements. Here is a summary of the options we found:

1. Perform the education as part of a physician office visit (99212-99215, office or other outpatient services, or 99395-99397, preventive medicine visits). Stephensons department schedules diabetes education services to be delivered either before or after a regular office visit by the patient. He notes that this is feasible in his setting, but may not work in practices that do a significant amount of diabetes education.

We do light management (of diabetic patients), order the drugs, things like that, he explains. We have an endocrinology department (at the clinic) that does the more complicated stuff. We just bill it out under the E/M service the physician provided.

Ethridge says it might be better for some internal medicine practices to schedule diabetes education sessions and use the office visit codes to bill the visit as counseling, if the diabetes counseling exceeds 50% of the time spent during the visit.

Of course this would have to be face-to-face with the physician, with the time and subject documented, she notes.

2. Bill using 99211. When the physician does not see the patient, code 99211 even though reimbursement is lower. Coding experts caution that Medicare requires services by non-physician providers to meet its incident to requirements.

Tip: To meet the definition of incident to, the service performed must be an integral part of the overall care provided by the physician. For Medicare, this means that the physician is on the premises and directly supervises the care provided. Documentation must show the physician involvement in the history, examination, and medical decision-making.

It might be feasible for a person other than the physician to use this code as long as the physician is on the premisesperhaps having the patient meet with the RN for the education, Ethridge says.

Other payers that accept this code might not require the service to be incident to or may have a different definition, but practice managers and billers should check with each carrier before submitting.

3. Use CPT code 97535 (self care/home management training). Ethridge has a March 1996 letter from the American Medical Associations Department of Coding and Nomenclature that says 97535, listed as part of the Physical Medicine-Therapeutic Procedures codes 97110-97546, can be used for diabetes education. However, her Medicare carrier has informed her that they will not reimburse for diabetes education billed with this code and practices must use the new HCPCS codes. It would probably work for other payers, though, she says.

Note: Several practice management consultants contacted by IMCA feel that HCFA may alter its certification requirements for the use of the new codes, particularly re-evaluating the required participation by the American Diabetes Association. We will keep you up-to-date in future issues.

What is required for G0108 and G0109?

Large multi-speciality practices or practices with a large number of diabetic patients may find it cost-effective to develop their own accredited diabetes education program in order to use the new codes. These are the requirements for billing G0108 and G0109.

1. Must have certified providers. In practical terms, this simply means that HCFA will only recognize the diabetes education provided by physicians and non-physician providers eligible to be paid under the Medicare physician fee schedule.

2. Practices must get American Diabetes Association (ADA) certification. To satisfy the quality standards requirements, the practice must meet the ADAs National Diabetes Advisory Board structural and process standards for a diabetes education program. (See insert.)

Among other things, these requirements include establishing a standing advisory committee that includes a physician, nurse educator, dietitian, behavioral science expert, consumer, and community representative to oversee the program and designate a coordinator responsible for program planning, implementation, and evaluation.

According to the HCFA program, a physician or practice must bill the service provided using a standard E/M code and attach a Certificate of Recognition from the ADA before it can become eligible to submit a claim using the new codes.

Tip: Internal medicine practices can obtain information about the certification process and apply for accreditation by writing to the American Diabetes Association National Office, Attn: Diabetes Education Recognition, 1660 Duke Street, Alexandria, VA, 22314. Phone: 1-888-232-0822. A complete list of accreditation requirements, including the review criteria, is available at the associations web site, http://www.diabetes.org.

3. Non-physician practitioners must meet certain requirements. If the diabetes education service is delivered by a physician assistant (PA), it must be furnished under the direct supervision of a physician. The employer of the PA must bill Part B of the Medicare program using the PAs own billing number for services performed by the PA or those that are incident-to a physician service. Clinical nurse specialists (CNSs) and nurse practitioners (NPs) may bill Part B directly for services that are performed in collaboration with a physician or services furnished incident-to the services of a physician. CNSs and NPs must also bill under their own provider numbers. An exception to this requirement is services delivered in a rural health clinic (RHC) or federally qualified health center (FQHC). In these centers, payment for non-physician services is bundled under the facility payment.