Pulmonology Coding Alert

When you report educational services your pulmonologists offer, you're going to have to switch sections depending on provider.

Physician educational opportunities fall under E/M or preventive medicine services, but don't forget three little codes for "Education and Training for Patient Self-Management" for nonphysician practitioners:

• 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.

Keep these factors in mind to determine if you should add this series to your encounter sheet.

You should report CPT's health and behavior assessment/intervention codes (96150-96155, Health and behavior assessment [e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires], each 15 minutes face-to-face with the patient ...) for nonphysician health professionals instead of for your physicians. CPT also intends for you to report the codes for patient self-management education and training for services rendered by nonphysician practitioners.

A physician "would instead use an E/M code when providing these services," says Richard H. Tuck, MD, FAAP, at PrimeCare of Southeastern Ohio.

Take note: CPT places several requirements on the ordering and performing of patient self-management education (98960-98962):

1. A physician must prescribe the education and training.

2. A qualified healthcare professional must provide the services using a standardized curriculum.

3. The nonphysician practitioner'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.

Example: A respiratory therapist (RT) teaches an asthmatic patient and his parents from a standardized curricula the fundamental concepts about asthma and environmental factors contributing to the patient's attacks, including his home and school environment. She teaches him ways to reduce attacks, including self-monitoring and proper medication use. The RT assesses the patient, provides the curriculum and established a plan for follow-up evaluation and ongoing assessment of outcomes to identify necessary treatment adjustments to improve his quality of life. Report 98960 for this encounter.

Unlike the codes for preventive counseling and 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," state 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 with a standardized curriculum that is specific in design with tools and schedules to follow up with the doctor, nurses and pharmacists," Tuck explains.

Don't count nutrition counseling as education and training, however.

"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.

Nebulizer note: Double-check that you're not reporting 98960-98962 for patient education regarding nebulizers or similar devices. Reporting 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device) is more accurate.

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.