reimbursement getting paid for what you do. enhancing reimbursement: what do you need to know? types...
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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
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
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
648.03
• Antepartum diabetes mellitus
• The state of pregnancy in women with pre-existing diabetes mellitus
• Does not include GDM
• 648.03 is a specific code that 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
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 Service Description
• In 1 week• Assess care plan, diet,
weight gain, adjust diet, exercise, meds as needed
• ICD-9 648.83 antepartum• ICD-9 648.84 postpartum
• Follow-Up – Length of Visit
• 97803 MNT Reassessment and Intervention (15 min each)
• 99214 F/U Outpatient Service (25 min each) 1 hour
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, sick-
day 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, sick-
day 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, sick-
day 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 non-pregnant 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.