Primary Care Coding Alert

Question: We have a nurse practitioner (NP) in our office that offers diabetes education. For Medicare patients, would it be correct to use G0108, or is 98960 a better choice?

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Answer: Code choice for diabetes self-management training (DSMT) is dependent on several things: the credentials and accreditation of the provider offering the education and the number of patients participating in the educational session. Code G0108 (Diabetes outpatient self-management training services, individual, per 30 minutes), and its group session counterpart G0109 (Diabetes outpatient self-management training services, group session [2 or more], per 30 minutes), can only be used for Medicare Part B patients if the provider is accredited per Centers for Medicare and Medicaid Services (CMS) guidelines (See www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/DSMT-Accreditation-Program.html for further details).

Under Medicare guidelines, both G0108 and G0109 can be provided by physicians and qualified health care professionals, as well as nonphysician QHPs (such as such as physician assistants [PAs], certified registered nurse practitioners [CRNPs], or clinical nurse specialists [CNS]) depending on the scope of their practice as defined by state law.

CPT^® guidelines differ to the point where services are defined by several different codes. If the education is provided by a physician or QHP in a group setting, then you would 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)). This can only be used for group sessions; CPT^® does not recognize individual patient diabetes education when offered by a physician or QHP, and a parenthetical instruction preceding code 98960 directs you to see the appropriate evaluation and management (E/M) codes for counseling and education provided by a physician to an individual.

Per CPT^®, individual diabetes education must be provided by a qualified, nonphysician healthcare professional using the time-based code 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). Qualified nonphysician healthcare professionals can also provide group diabetic instruction using either 98961 (… 2-4 patients) or 98962 (… 5-8 patients) as appropriate.

And while CPT^® guidelines do not require any of the services to be furnished by accredited providers, the guidelines for 98960-98962 stipulate that “the qualifications of the nonphysician healthcare professionals and the content of the educational and training program must be consistent with guidelines or standards established or recognized by a physician society, nonphysician healthcare professional society/association, or other appropriate source.”

Putting it all together: For DSMT provided to an individual Medicare patient by a nurse practitioner, you would use G0108, providing your nurse practitioner is accredited per CMS guidelines.

For a complete list of Medicare rules and regulations regarding DSMT using HCPCS codes G0108 and G0109, go to www.cdc.gov/diabetes/dsmes-toolkit/reimbursement/medicare.html.