Primary Care Coding Alert

Question:  We have a RN who wants to provide a diabetic education class in a group setting. The program is not accredited, and I understand that we cannot use the G codes. If the MD is there and provides a face-to-face encounter with each patient, can he bill an E/M for each patient and just have the diabetes education training included in the E/M? Or is there a better way to bill for this service. The ‘98960-62’ codes seem appropriate too, but Medicare does not pay for those codes. Please help.

Michigan Subscriber

Answer: Diabetes education may be provided in a group or individual setting, or a combination of both, and it may be provided by a physician/other qualified health care professional or ancillary staff, such as an RN, depending on the client’s needs and the practice’s capabilities.How you report it will depend on how it is provided and to whom.

If the RN provides the diabetic education in a group setting without the involvement of the physician, then one option may be to use the education and training for patient self-management codes (98960-98962), as you noted, especially 98961 or 98962, which are particular to group education. Per CPT®, to use these codes, the RN must be using a standardized curriculum and the training must be prescribed by the physician. However, as you also noted, Medicare does not pay for these codes, because it considers them “bundled.” Other payers may allow payment for these services. 

Another option is to have the nurse provide the education incident to an E/M encounter that the physician provides to each patient, as you suggested. In this case, the education is not separately reportable from the E/M that the physician will otherwise bill each patient. 

If the education is provided by your physician to a group, you may use 99078 (Physician or other qualified health care professional qualified by education, training, licensure/regulation [when applicable] educational services rendered to patients in a group setting [e.g., prenatal, obesity, or diabetic instructions]) as an adjunct to the basic service (i.e. in addition to whatever other service(s) was provided to the patient; however, Medicare and many private payers treat this code as “bundled” and will not allow separate payment for it, either. For counseling/ education provided by your physician to an individual in a face-to-face encounter, simply choose the appropriate E/M code and do not code anything separately for education).

Finally, as you alluded Medicare has “G” codes (G0108 and G0109) for diabetes outpatient self-management training services. However, these codes do require the program to be accredited, which is not applicable in your case.