Reimbursement
Getting Paid for What
You Do
Enhancing Reimbursement:
What do You Need to Know?
•
•
•
•
•
•
Types of health plans and differences
Authorization process
Coding process
Forms to use
People to contact for questions
Type of Sweet Success program setting
OVERWHELMING?
YES!!!
Types of Health Plans
• Fee for Service
• HMO (managed care)
• Medicaid/Medi-Cal (CPSP)
• Medi-care
CODING 101
ICD-9,CPT-4 Codes,
HCPCS, E/M, DMST/MNT
TYPES OF BILLING CODES
• “What you do” Codes
• CPT-4 - exams, procedures, services
• Healthcare Common Procedure Coding
System - HCPCS (“hick picks”) - CPSP “Z
codes,” supplies, drugs, DME, G codes
• “Why you do it” Codes
• ICD-9 - diagnosis and symptoms
You must document and code
both for each client you see to
get reimbursed!
Diagnosis Coding
“Why We Do It” Codes
• ICD-9 (International Classification of
Diseases), 2010
• Always use a 5-digit code
• In pregnancy complicated by diabetes, this
code starts with 648
• Codes can only be used as diagnostic
when they are 5 digits
2010 ICD-9 Specific Codes
• The entire code 648 is listed as ”complications of
pregnancy, childbirth, or the puerperium”
• 648.00 is diabetes mellitus complicating
pregnancy, childbirth, or the puerperium
•
http://www.icd9data.com/2010/Volume1/630-679/640-649/648/default.htm
648.01
• Diabetes mellitus of mother with delivery
• This is a code that can be used to specify
a diagnosis
648.02
• Diabetes mellitus of mother with delivery
with postpartum complications
648.03
• Antepartum diabetes mellitus
• The state of pregnancy in women with preexisting diabetes mellitus
• Does not include GDM
• 648.03 is a specific code that can be used
to specify a diagnosis
648.04
• Postpartum Diabetes Mellitus
• Can be used to specify a diagnosis
648.80
• 648.8 (+ 1 digit) is abnormal glucose
tolerance of mother complicating
pregnancy, childbirth, or the puerperium
• Unspecified as to episode of care
648.83
• It can be used to specify a diagnosis
• 648.83 is abnormal glucose tolerance of
mother antepartum
• GDM
648.84
• 648.84 is abnormal glucose tolerance of
mother postpartum
• It can be used to specify a diagnosis
Specificity and accuracy are
the keys to successful billing!
CPT Codes
“What We Do” Codes
• CPT (Current Procedural Terminology)
codes are numbers for medical, surgical, &
diagnostic procedures
• CPT codes are used by all healthcare
practitioners to bill for their services
•
http://patients.about.com/od/costsconsumerism/a/cptcodes.htm
CPT Coding
• Some health plans only cover specific
diabetes education codes
• Medi-cal - CPSP “Z” codes
• Medicare – “G” codes
• Talk to your insurers & find out what codes
they will cover
Diabetes Education
& CPT Codes
• Most insurers only cover diabetes
education codes if education is done by
a qualified provider in a physician’s
office or a hospital-based outpatient
program
“Qualified” Providers
of Diabetes Education
• Certified Diabetes
Educator
• Physician
• Clinical Psychologist
• Clinical Social
Worker
• Nurse Midwife
• Nurse Practitioner
• Physician’s
Assistant
• Registered Dietitian
CPT Codes for Diabetes
Supplies
• CPT codes are also used for billing
diabetes testing & injection supplies
Medicare “G” Codes
• Diabetes Self-management
Education/Training (DSME/T) individual or
group
• Medical Nutrition Therapy (MNT)
• Limited number of visits
Evaluation & Management
Codes (E/M)
•
•
•
•
•
•
Outpatient services
99245 Initial Consultation
99201-99205 New patients
99211-99215 Established patients
Level of service depends on initial or follow up visit
Choose codes accurately reflecting level & intensity of
services given
• Level of service has 3 parts:
History, examination, complexity of medical decision
making
Comprehensive Perinatal
Support Program (CPSP)
• “Z” codes
• Specific only to Medi-cal CPSP providers
• Allotted units for medical, education,
nutrition and psychosocial aspects of care
GDM Diet
• Initial Service Descriptions
• Medical, family, OB hx
• Individual self-care plan
includes MNT, exercise,
SMBG, meds, log book,
psychosocial
• Referrals as needed
• Dx code (ICD-9) 648.83
• PPO plan (fee for service)
•
•
•
•
Initial - Length of Visit
1-1/2 hours
CPT Codes:
99205 Initial Outpatient
Service (60 min)
• 99245 Initial Consultation (80
min)
• 97802 Initial Assessment and
Intervention for MNT (15 min
each)
• 99371 One time fee for case
coordination between care
givers, referrals, etc.
GDM Diet
• Follow-Up – Length of
• Follow-Up Service
Visit
Description
• 97803 MNT
• In 1 week
Reassessment and
Intervention (15 min
• Assess care plan, diet,
each)
weight gain, adjust diet,
F/U Outpatient
exercise, meds as needed • 99214
Service (25 min each) 1
• ICD-9 648.83 antepartum
hour
• ICD-9 648.84 postpartum
Preconception DM1, DM2
• Initial Service Descriptions
• Assess lifestyle limitations,
diabetes knowledge & skills,
general health & obstetrical
history.
• Provide adequate knowledge
for: understanding
complications associated with
diabetes & pregnancy;
effective behavioral changes to
improve diabetes self-care;
dietary, activity and insulin
adjustments necessary for
continued good control of
diabetes; planning and early
identification of pregnancy.
•
•
•
•
Initial Length of Visit
2 hours
CPT Codes:
99205 Initial Outpatient
Service (60 min)
• 99245 Initial Consultation (80
min)
• 97802 Initial Assessment and
Intervention for MNT (each 15
min increment)
• 99371 One time fee for case
coordination between care
givers, referrals, etc.
Preconception DM1, DM2
• Follow-Up Service
Description
• In 1 week
• Make adjustments in plan
as needed
• Discuss lab results, etc.
• Refer as needed
•
•
•
•
Follow-Up Visits
30 to 60 minutes
CPT Codes:
97803 MNT
Reassessment and
Intervention (15 min
each)
• 99214 F/U Outpatient
Service (25 min each)
DM1, DM2 Pregnant
• Initial Service
Descriptions
• Medical, family, OB hx
• Individual self-care plan
includes MNT, exercise,
SMBG, meds, log book,
psychosocial
• Referrals as needed
•
•
•
•
Initial - Length of Visit
2 hours
CPT Codes:
99205 Initial Outpatient
Service (60 min)
• 99245 Initial Consultation (80
min)
• 97802 Initial Assessment and
Intervention for MNT (15 min
each)
• 99371 One-time fee for case
coordination between care
givers, referrals, etc.
DM1, DM2 Pregnant
• Follow-Up Service
Description
• In 1 week
• Assess care plan, diet,
weight gain, adjust diet,
exercise, meds as
needed
• Follow-Up – Length of
Visit
• 1 hour
• CPT Codes:
• 97803 MNT
Reassessment and
Intervention (15 min
each)
• 99214 F/U Outpatient
Service (25 min each)
DM1 & DM2
• Subsequent Follow-Up
Service Description
• Clarify diet, SMBG, sickday rules, breastfeeding,
planning future
pregnancies, &
postpartum healthy
lifestyle
• Frequency is determined
by overall control &
adherence
• Follow-Up – Length of
Visit
• 30 – 60 minutes
• CPT Codes:
• 97803 MNT
Reassessment and
Intervention (15 min
each)
• 99213 F/U Outpatient
Service (15 min each)
Impaired Glucose Tolerance of
Pregnancy (1 abnormal BG 3-hr OGTT)
• Initial Service
Description
• Medical, family, OB hx
• Individual self-care plan
includes MNT, exercise,
SMBG, meds, log book,
psychosocial
• Referrals as needed
•
•
•
•
Initial - Length of Visit
1 hour
CPT Codes:
99205 Initial Outpatient
Service (60 min)
• 97802 Initial Assessment
and Intervention for MNT
(15 min each)
• 99371 One time fee for
case coordination
between care givers,
referrals, etc.
GDM - Diet
• Subsequent Follow-Up
Service Description
• 1 to 2 week intervals
• Clarify diet, SMBG, sickday rules, breastfeeding,
planning future
pregnancies, &
postpartum healthy
lifestyle
• Frequency is determined
by overall control &
adherence
• Follow-Up – Length of
Visit
• 30 – 60 minutes
• CPT Codes:
• 97803 MNT
Reassessment and
Intervention (15 min
each)
• 99213 F/U Outpatient
Service (15 min each)
GDM - Oral Hypoglycemic
Agents (OHAs)
• Initial Service
Description
• Medical, family, OB hx
• Individual self-care plan
includes MNT, exercise,
SMBG, meds, log book,
psychosocial
• Referrals as needed
• Follow-Up in 1 Week
• Evaluate plan & med
effectiveness
• Subsequent Follow-Up
in 1-2 week Intervals
•
•
•
•
Initial - Length of Visit
2 hours
CPT Codes:
99205 Initial Outpatient
Service (60 min)
• 99245 Initial Consultation
(80 min)
• 97802 Initial Assessment
and Intervention for MNT
(15 min each)
GDM - Insulin
• Initial Service Description
• Medical, family, OB hx
• Individual self-care plan
includes MNT, exercise,
SMBG, meds, log book,
psychosocial
• Initial insulin instruction
• Referrals as needed
•
•
•
•
Initial - Length of Visit
2 hours
CPT Codes:
99205 Initial Outpatient
Service (60 min)
• 99245 Initial Consultation (80
min)
• 97802 Initial Assessment and
Intervention for MNT (15 min
each)
• 99371 One time fee for case
coordination between care
givers, referrals, etc.
GDM - Insulin
• Follow-Up Service
Description
• 1 week - determine
effectiveness of care
plan, diet and weight
gain, make adjustments
in diet, exercise, and
determine if insulin
adjustments are needed.
• Follow-Up – Length of
Visit
• 1 hour
• CPT Codes:
• 97803 MNT
Reassessment and
Intervention (15 min
each)
• 99214 F/U Outpatient
Service (25 min each)
GDM - Insulin
• Subsequent Follow-Up
Service Description
• 1 to 2 week intervals
• Clarify diet, SMBG, sickday rules, breastfeeding,
planning future
pregnancies, &
postpartum healthy
lifestyle
• Frequency is determined
by overall control &
adherence
• Follow-Up – Length of
Visit
• 30 to 60 minutes
• CPT Codes:
• 97803 MNT
Reassessment and
Intervention (15 min
each)
• 99213 F/U Outpatient
Service (15 min each)
Postpartum Follow-Up
•
•
•
•
•
Service Description
Assessment postpartum to
determine MNT in non-pregnant
state, lactation needs, and other
medical conditions requiring
adjustment of the diet.
Insulin adjustments for nonpregnant state, blood glucose
monitoring, risk reduction
counseling regarding weight
control, exercise and follow-up
testing for diabetes (if GDM).
Emphasis on appropriate
contraception and family planning
for future pregnancies and to
promote preconception planning.
Referral to other providers as
needed.
•
•
•
•
•
•
•
Length of Visit
30 – 60 minutes
CPT Codes:
99214 F/U Outpatient Service (15
min each) or
99215 F/U Outpatient
Coordination of Care with other
providers or agencies.
97803 MNT Reassessment and
Intervention (each 15 min.)
99371 One time fee for case
coordination between care givers,
referrals, etc.