Pulmonology Coding Alert

If you're not using patient self-management codes, you could be missing reimbursement opportunities

Don't overlook a three-code series -- new to CPT this year -- that describes educational services your physicians may provide. These basics from the experts will help you determine if you should add this series to your encounter sheet.
 
CPT 2006 introduced a medicine subsection titled "Education and Training for Patient Self-Management," which includes these codes:

• 98960 -- Education and training for patient self-management by a qualified, nonphysician healthcare professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient

• 98961 -- ... 2-4 patients

• 98962 -- ... 5-8 patients.

Reserve Self-Management for Non-MD Education

As with the health and behavior assessment/intervention codes (96150-96155), CPT intends nonphysician practitioners to use the codes for patient self-management education and training. "The pediatrician or a nurse practitioner would instead use an E/M code when she provides these services," says Richard H. Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio.
 
CPT places several requirements on the ordering and performing of 98960-98962:
 
1. A physician must prescribe the education and training, Tuck says.
 
2. A qualified healthcare professional must provide the services using a standardized curriculum.
 
3. The nonphysician's qualifications and the program's contents "must be consistent with guidelines or standards established or recognized by a physician society, nonphysician healthcare professional society/association, or other appropriate source," according to CPT's introductory patient self-management education and training notes.
 
4. The service must be face-to-face.

Consider Asthmatics Potential Candidates

Unlike the codes for preventive counseling and/or risk-factor reduction intervention (99401-99412), the codes for patient self-management education and training require the individual to have an established condition. The educational and training services teach the patient "how to effectively self-manage the patient's illness(s)/disease(s) or delay disease comorbidity(s) in conjunction with the patient's professional healthcare team," states CPT's introductory notes for 98960-98962.
 
Qualifying candidates for 98960-98962 could include patients with asthma, Tuck says. "The individual must be enrolled in a disease management program that is specific in design with tools and schedules to follow up with the doctor, nurses and pharmacists," he says.
 
Warning: Don't count nutrition counseling as education and training. "Codes 97802-97804 are specifically for medical nutrition therapy," says Anne Riehl, RD, with Mid Ohio Nutrition in Columbus. Codes 98960-98962 may encompass more medical education, she says.

Remind Payers of Program's Savings

Although Medicare considers the patient self-management education and training codes bundled services (and does not pay for these codes), you may still be able to receive payment for 98960-98962 as part of the disease management programs promoted by some major insurance companies. Many payers understand the value of disease management programs, Tuck says: "Insurers realize that these programs significantly improve patients' health and as a result decrease emergency department visits and hospitalizations." Check with each insurer because disease management programs require application and insurer acceptance into their network.