Reimbursement Getting Paid for What You Do. Enhancing Reimbursement: What do You Need to Know? Types...

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 pre-existing 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 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



Intervention for MNT (each 15 min increment)


Preconception DM1, DM2


• 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


• Referrals as needed

• Initial - Length of Visit• 2 hours• CPT Codes:• 99205 Initial Outpatient




• 99371 One-time fee for case coordination between care givers, referrals, etc.

DM1, DM2 Pregnant


• In 1 week• Assess care plan, diet,

weight gain, adjust diet, exercise, meds as needed


• 1 hour• CPT Codes: • 97803 MNT



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


• 30 – 60 minutes

• CPT Codes: • 97803 MNT



Impaired Glucose Tolerance of Pregnancy (1 abnormal BG 3-hr OGTT)• Initial Service

Description• Medical, family, OB hx• Individual self-care plan


• 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)


GDM - Diet

• Subsequent Follow-Up Service Description

• 1 to 2 week intervals• Clarify diet, SMBG, sick-




• 30 – 60 minutes• CPT Codes: • 97803 MNT



GDM - Oral Hypoglycemic Agents (OHAs)

• Initial Service Description

• Medical, family, OB hx• Individual self-care plan


• 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


• Initial insulin instruction• Referrals as needed

• Initial - Length of Visit• 2 hours• CPT Codes: • 99205 Initial Outpatient





GDM - Insulin


• 1 week - determine effectiveness of care plan, diet and weight gain, make adjustments in diet, exercise, and determine if insulin adjustments are needed.


• 1 hour• CPT Codes:• 97803 MNT



GDM - Insulin

• Subsequent Follow-Up Service Description

• 1 to 2 week intervals• Clarify diet, SMBG, sick-




• 30 to 60 minutes• CPT Codes: • 97803 MNT



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.)


Reimbursement Getting Paid for What You Do. Enhancing Reimbursement: What do You Need to Know? Types...

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