Pediatric Coding Alert

Question: A pediatrician and PA are educating some parents on diabetes, exercise, and nutrition. The plan is to bring the patients in at 4:45 to workup the patient, and start the group session at 5 p.m. for about 45 minutes to an hour. Can practices report these services? Will carriers pay for them?

North Carolina Subscriber

Answer: You have a couple options depending on what insurers cover.

Option 1: For the office visit (workup), report the appropriate level E/M service, such as 99212 (Office or other outpatient visit for the evaluation and management of an established patient ...). Use physician group education codes for the 45-minute counseling session.

Since the education is in a group setting provided by a physician or nonphysician practitioner (the physician assistant [PA]) and the patients have an established illness (diabetes), the sessions fall under 99078 (Physician educational services rendered to patients in a group setting [e.g., prenatal, obesity, or diabetic instructions]).

This code is not time-based and can be coded per patient. You can report the office visit appended with modifier 25  (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) in addition to the physician educational services.

Pitfall: Because the Medicare Physician Fee Schedule considers 99078 a bundled service and assigns it no relative value units (RVUs), Medicaid carriers and private payers may not pay for the educational services code.

Option 2: You might want to provide the American Diabetes Association's National Standards curriculum that N.C. Medicaid covers for diabetes self-management training,

which aims to reduce exacerbations and improve diabetes symptoms through exercise, nutrition, personal goals, and lifestyle habits. Physicians are eligible for providing this service, and PAs can bill it incident-to the physician. You would use a group code of G0109 (Diabetes outpatient self- management training services, group session [2 or more], per 30 minutes).

The individual code, however, requires a minimum of 30 minutes: G0108 (Diabetes outpatient self-management training services, individual, per 30 minutes). To read about enrollment, referral requirements, frequency allowances, and other requirements, see www.ncdhhs.gov/dma/mp/1A24.pdf. Codes G0108 and G0109 have 0.64 and 0.36 RVUS. Report these codes based on time. So if you provided an hour of group DSMT, you would report G0109 x 2, which pays a national rate of approximately $26.