Primary Care Coding Alert

Question: To meet the needs of a number of our patients with diabetes, our provider decided to organize a group meeting for diabetes education. What is the best code to use for a group session like this, and what are the pros and cons of using it?

Oklahoma Subscriber

Answer: Choosing the correct code for group education sessions depends on who leads the sessions and how many patients will be served at each one.

If a physician plans a session and will lead it, you may be able to 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 (eg, prenatal, obesity, or diabetic instructions)). The pro for using this code is that it is not a time-based code, which means you can submit it for each patient that is present at the time of the session.

The con, though, is that some payers may not accept it, so be sure to check the guidelines before submitting it for payment. Whatever the case, you must include a diagnosis code related to the service. Also, because CPT^® codes in the 99000-99091 series are considered an adjunct to a basic service, some payers may expect you to use an appropriate evaluation and management (E/M) code with modifier 25 (Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service) appended in addition to 99078.

However, when group sessions are led by a nonphysician provider (NPP) who does not meet the CPT^® definition of a "qualified health care professional," you will need to document 98960 (Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient), 98961 (... 2-4 patients), or 98962 (... 5-8 patients). The con for using this code is that the NPP must use a standardized curriculum, though the pro is that the curriculum may be modified for the health needs and cultural background of the patient participants.

Coding alert: If the patients are Medicare beneficiaries, and the education in question qualifies as diabetes outpatient self-management training, then you would use G0109 (Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes).