Pediatric Coding Alert

Your practice could benefit from patient self-management codes

Because your plate is full relearning affected CPT Codes that are already on your superbill, you may overlook a new three-code series, which describes educational services you may provide.

These basics from the experts will help you determine if you want to add this new series to your encounter sheet. CPT 2006 introduces a medicine subsection titled “Education and Training for Patient Self-Management,” which includes these codes:

• 98960--Education and training for patient self-management by a qualified, nonphysician healthcare professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient

• 98961--… 2-4 patients

• 98962--… 5-8 patients.

Reserve Self-Management for Non-Md Education

Similar to the health and behavior assessment/intervention codes (96150-96155), CPT intends nonphysicians to use the patient self-management education and training codes. “The pediatrician or a nurse practitioner would instead use an E/M code when she provides these services,” says Richard H. Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio.

CPT places several requirements on the ordering and performing of 98960-98962.

1. A physician must prescribe the education and training, Tuck says.

2. A qualified healthcare professional must provide the services using a standardized curriculum.

3. The nonphysician’s qualifications and the program’s contents “must be consistent with guidelines or standards established or recognized by a physician society, nonphysician healthcare professional society/association, or other appropriate source,” according to CPT’s introductory patient self-management education and training notes.

Consider Asthmatics, Diabetics Potential Candidates

Unlike counseling and/or risk-factor reduction intervention codes (99401-99412), the patient self-management education and training codes require the individual to have an established condition. The educational and training services teach the patient “how to effectively self-manage the patient’s illness(s)/disease(s) or delay disease comorbidity(s) in conjunction with the patient’s professional healthcare team,” states CPT’s introductory notes for 98960-98962.

Tuck suggests that qualifying candidates for 98960-98962 could include patients with asthma or diabetes. “The individual must be enrolled in a disease management program that is specific in design with tools and schedules to follow up with the doctor, nurses and pharmacists,” he says.

Warning: Don’t count nutrition counseling as education and training. “Codes 97802-97804 are specifically for medical nutrition therapy (MNT),” says Anne Riehl, RD, with Mid Ohio Nutrition in Columbus. Codes 98960-98962 may encompass more medical education, such as insulin management, she says.

Remind Payers of Program’s Savings
 
Although the National Physician Fee Schedule has not assigned any values to the patient self-management education and training codes, you may still be able to receive payment for 98960-98962 as part of the programs most major insurance companies promote. Many payers understand the value of disease management programs, Tuck says: “Insurers realize that these programs significantly improve patient’s health and as a result decrease emergency department visits and hospitalizations.”