Reimbursement/Coding

THE INFORMATION REGARDING REIMBURSEMENT IS PROVIDED FOR INFORMATIONAL PURPOSES ONLY AND REPRESENTS NO STATEMENT, PROMISE, OR GUARANTEE BY THE JOHNSON & JOHNSON DIABETES INSTITUTE, LLC CONCERNING LEVELS OF REIMBURSEMENT, PAYMENT, OR CHARGE. SIMILARLY, ALL CPT AND HCPCS CODES ARE SUPPLIED FOR INFORMATIONAL PURPOSES ONLY AND REPRESENT NO STATEMENT, PROMISE, OR GUARANTEE BY THE JOHNSON & JOHNSON DIABETES INSTITUTE, LLC THAT THESE CODES WILL BE APPROPRIATE OR THAT REIMBURSEMENT WILL BE MADE. IT IS NOT INTENDED TO INCREASE OR MAXIMIZE REIMBURSEMENT BY ANY PAYOR. WE STRONGLY RECOMMEND THAT YOU CONSULT YOUR PAYOR ORGANIZATION WITH REGARD TO ITS REIMBURSEMENT POLICIES.

Using SMA tool code for a shared visit

Go to Patient Cases section in your book and review the following:

• Kenny, April and 8 peers & parents• Visit is planned for 90 min: vitals, MNT by RD,

brief consult with HCP & peer discussion of lapses in self-mgmt

• Code for this visit using tool

Coding for SMA

• What determines the 4th digit?• What determines the 5th digit? • What education code is used?• How long does the education have to be?• What CPT code is most likely?

Diabetes Coding

Basecode Manifestations

Add as 4th

digit

Complete Code

DM1 Controlled: Add as 5th

digit

TDM1 Uncontrolled:

Add as 5th digit

TDM2 Controlled: Add as 5th

digit

DM2 Uncontrolled:

Add as 5th digit

  

Always use

5 digit code

Code to highest

specificity  

250 None 0 250.0X 1 3 0 2

250 Renal 4 250.4X 1 3 0 2

250 Ophthalmologic 5 250.5X 1 3 0 2

250 Neurological 6 250.6X 1 3 0 2

250 Peripheral Circulatory 7 250.7X 1 3 0 2

250 Other specified 8 250.8X 1 3 0 2

250 Unspecified 9 250.9X 1 3 0 2Gestational

Diabetes 648.03

Example: Code diabetes first: 250.XX

Code also manifestation: 250.5 Retinopathy

Coding for SMA

• 4th digit? Complications/manifestations • 5th digit? Glycemia controlled vs. uncontrolled• What education code is used? 97804• How long does the education have to be? 30m• What CPT code is most likely? 99213

DSME and MNT Complimentary

• Every single patient should receive BOTH:

– Diabetes Self-Management Education (DSME)• 10 hrs in initial year

• 2 hrs in all subsequent years

– Medical Nutrition Therapy (MNT)

• 3 hrs in initial year

–Extra hrs can be requested and reimbursed

• 2 hrs in all subsequent years

Avoiding paybacks

Pt Completed/Provider Reviewed Nurse and Provider Completed

Quick, Simple and Scan it!

SMA:E/M Visit

Aver. # pts seen 10

# individual E/M pt visits billed by physician/NPP and typical level of

10 x code 99214** @ $/pt

Aver. insurance reimbursement

E/M: $/ 1 hr

DO THE MATH

Traditional Practitioner Appointment:

DM Management Only

10

10 x code 99214** @ $/pt

E/M: $/ 3.3 hrs

Aver. # pts seen

# individual E/M pt visits billed by physician/NPP and typical level of

Aver. insurance reimbursement