Reimbursement/Coding
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Transcript of Reimbursement/Coding
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