Primary Care Coding Alert

Question: We have a certified diabetic educator who sees some of our patients, and I have two questions about how to bill for the services she provides. 1) When patients spend time with her, what CPT code should we assign? 2) On occasion, a patient comes in to see the doctor, and he treats them. Subsequently, he refers them to the diabetic educator, and she sees them on the same day. How do we code both sessions? The diabetic educators claims are billed under the doctors name because she is not set up as a provider with the patients insurance company.

Texas Subscriber

Answer: The answer to this question depends on whether the services provided by the diabetic educator can be categorized as incident-to. Medicare defines incident-to as services or supplies that are furnished as an integral, although incidental, part of the physicians personal professional services in the course of a diagnosis or treatment of an injury or illness.

For a service to be covered as incident-to services, however, the following criteria must be met:

1. The services or supplies must be offered in the
physicians office or clinic.

2. The services must be rendered without charge or
included in the physicians bill.

3. Physicians must provide personal supervision to
auxiliary personnel (i.e., physicians presence in the office at the time the service was rendered), and the existence of a diagnosis and treatment plan must be
previously established by the physician (i.e., the
physician must have seen the patient first).

4. The non-physician provider must be a part-time,
full-time or leased employee of the supervising
physicians group practice or other entity that
employs the physician.

If the diabetic educator meets all the criteria necessary for incident-to, there are codes that you can assign to reflect the level of service provided. If the patient being seen is a Medicare beneficiary, you would assign code G0108 (diabetes outpatient self-management training services, individual, per session) or G0109 (diabetes self-management training services, group session, per individual). If the patient has commercial insurance, code 99078 (physician educational services rendered to patients in a group setting [e.g., prenatal, obesity, or diabetic instructions) would be appropriate to use.

Prior to billing for diabetes outpatient self-management training services, all providers must submit to the Medicare contractor an Education Recognition Program (ERP) certificate from the American Diabetes Association (ADA).

If the physician sees the patient the same day as the diabetic educator, as the second part of your question indicates, you can bill for both. You would assign the appropriate evaluation and management code for the office visit and report G0108 or G0109 for Medicare, or 99078 for commercial carriers, for the diabetic educator.

Note: The Reader Questions were answered by Cynthia DeVries, RN, BSN, CPC, a coding and reimbursement coordinator for Lee Physicians Group, a 140-provider, multispecialty practice in Ft. Myers, Fla.