Wiki 98960, G0108, or 99211? Need help quick!

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JeannieG

JeannieG

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I was wondering if someone could help me with this little situation. We billed Medicare for 98960 for a patient that came in for Diabetes education. This was all that was done at this vist, nothing else was done. The RN MD was on site at time) spent 30 min. with the patient.

I tried to tell the MD that this is a bundled code per Medicare, but she wanted me to submit it anyway, alone and see what they say. I did as instruced, and yes...they denied it as "The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated." There was no other service, so there was no other bill they could adjudicate it with. She now wants me to submit it as a nurse visit, and do this for now, "until we can find someone who knows how to code this correctly". Apparently, the urgent unit that she helps at, does it all the time and they get paid for it.

Yes, I am new at this, and we don't do this very often, but we want to do this for our patients more often so I need to know how to do it correctly so we can get paid for this service too. I did try to tell her in the begining I didn't think they would pay for it. So before I just submit it again, (possibly incorrectly) I'm asking for help in here. I saw another thread that suggested G0108. Since this is a Medicare patient, should I use this code then? Will that get us paid? We also used DX of 250.00

I know 98960 will be denied, my question is, should I go with 99211 or G0108?
Thanks for your help.
 
I do want to thank you for your help on this.

For those of you who might be interested...I did some more invistigating and found that in order to get paid using codes G0108 and G0109, our RN (who would be taking the time to do this) would need to be a certified diabetic educator.

There is a great artical located on the AAFP site that talks about this.
http://www.aafp.org/fpm/990400fm/getting.html
& http://www.aafp.org/fpm/2001/0400/p14.html

(I do hope it was okay to post this)

So...because she is not certified in this, we are just going to submit 99211.
 
Does anyone know if it isn't a medicare patient and a nurse or pharmicists is doing any type of patient education what code you would use and get paid? Would you use 99211 or 98960.
Thanks
:confused:
 
I have a query pertaining to 98960. I have information which states that code 98960 is staus B code, i.e Medicare does not pay for it, then how come for few of them medicare has reimbursed 98960 ? I need Help on this as i am expriencing denial for 98960 staing its a bundled code. a) I have only this code 98960 for the visit and it got denied.
 
We have just run into this question as well. We are getting the CO-B15 denial saying that a qualifying service/procedure is required and M80 saying that it is bundled. This is the only service we are billing. The education was done by a staff RN and billed under the MD's Medicare provider ID. The code does not appear on the Fee Schedule. When I do a search on the MAC's website for code 98960, nothing is found. I notice that the dates of this discussion are 2010. Is this a code that used to be covered but is not any longer?
 
Hi , can someone help me ? I've been trying to bill CPT 98960 along with the E and M for commercial insurances . Just wanna know if this is bundled with 992xx codes . Thanks
 
Clealene said:
Hi , can someone help me ? I've been trying to bill CPT 98960 along with the E and M for commercial insurances . Just wanna know if this is bundled with 992xx codes . Thanks
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CMS has not priced it in the PFS for 2023 or 2024 and its indicated as a bundled code. For commercial insurance, I would refer to the payor policy- although most follow Medicare when it involves paying less. We have not had success in reimbursement for this code at our practice. Good luck!
BBundled CodePayment for covered services are always bundled into payment for other services not specified. If RVUs are shown, they are not used for Medicare payment.If these services are covered, payment for them is subsumed by the payment for the services to which they are incident. (An example is a telephone call from a hospital nurse regarding care of a patient).
 
Clealene said:
Hi , can someone help me ? I've been trying to bill CPT 98960 along with the E and M for commercial insurances . Just wanna know if this is bundled with 992xx codes . Thanks
Click to expand...
According to EncoderPro for Payers when I do an CCI check on 98960 with any of the E&M codes in the range of 99202-99215 I do show there are any CCI conflicts for 98960 being billed one of these E&M codes. I would question who is billing each of these services since the 98960 is for a qualified nonphysician provider, is the E&M also being by a qualified nonphysician provider who is eligible to bill for E&M services?

Since 98960 is not covered by Medicare it makes sense that this code is not on the PFS for 2023 and 2024, so I wouldn't necessarily follow Medicare. There may be commercial payers who do cover this service, but there are very likely to be detailed and specific guidelines for coverage of this service, so you'll need to know what the coverage guidelines or requirements are for each commercial payer you are planning to submit claims to for this service.

Also, it may seem unusual to the commercial payer to see 98960 billed for the same provider on the same DOS as the E&M so you are likely to receive a higher level of review or scrutiny when billing these codes together on a DOS with the same provider. They will likely be looking to see if the time requirements for 98960 are met and how you leveled the E&M, MDM or time. The provider needs to be very specific when documenting the time spent on 98960 and if you are coding E&Ms based on time, as many are doing now days, the documentation for the time spent on the E&M service needs to be very specifically documented. If you are billing the E&M based on MDM, then you only need to worry about the documentation regarding time for 98960. You still need to make certain that the documentation supports MDM associated with the level of E&M coded.
 
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