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 Always use 5 digit code Code to highest specificity Gestational Diabetes 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 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 2 Base code 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

Avoi ding payb ac ks

Pt Completed/Provider Reviewed k c i u Q Nurse and Provider Completed ! t i n a c S d n a e l p m i ,S

SMA: E/M Visit Aver. # pts seen 10 # individual E/M pt visits billed by physician/NPP and typical level of Aver. insurance reimbursement 10 x code 99214** @ /pt E/M: / 1 hr DO THE MATH

Traditional Practitioner Appointment: DM Management Only Aver. # pts seen # individual E/M pt visits billed by physician/NPP and typical level of Aver. insurance reimbursement 10 10 x code 99214** @ /pt E/M: / 3.3 hrs