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Watch frequency, duration when providing diabetes self-management training

Question: One of our practices is trying to bill for diabetes self-management training (DSMT) using codes 98960 (Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient [could include caregiver/family] each 30 minutes; individual patient) or G0108 (Diabetes outpatient self-management training services, individual, per 30 minutes).

The service is provided by a nurse practitioner, who is not a certified educator. Our dilemma is simple: Which code should we bill? The service is normally well-documented and includes face-to-face time. Here’s the scenario: The doctor sees the patient and orders diabetes self-management education. The patient comes back the next day or so, and the nurse practitioner will educate the patient for about 30 minutes.

Would this be medically necessary that a qualified provider provided a related E/M service the next day? I believe there are clinical guidelines for diabetes follow-up frequency.

Answer: First, select the code based on your payer and adhere to its rules on DSMT, particularly when it comes to frequency, advises Margie Scalley Vaught, CPC, Coding Pro technical adviser. The G code is a Medicare code, and Medicare’s Internet-only Manual (IOM) states that Medicare covers DSMT services for beneficiaries who:

  • Were recently diagnosed with diabetes.
  • Were determined to be at risk for complications from diabetes.
  • Were previously diagnosed with diabetes before becoming Medicare-eligible and are now eligible.
Have your non-physician practitioner (NPP) conduct DSMT if your patient fits one of the above categories, but be sure to stick to frequency guidelines to make sure you’re able to get reimbursed for the education. Medicare sets the limit at 10 hours of training for the initial year, notes Vaught.

Because Medicare emphasizes the DSMT service for newly diagnosed patients, it will only pay for two hours of DSMT service in subsequent years. Note also that a copayment applies, so make sure your patients are aware of that upfront to avoid a dispute later.

Be sure to cover yourself — and your patient — if you’re nearing the threshold. “The beneficiary is liable for services denied over the limited number of hours with referrals for DSMT,” states the IOM.

CPT code 98960 is a catch-all education code for patient self-management, which you’ll differentiate with appropriate diagnosis codes, according to official CPT guidelines.

Just be sure your NPP is the one providing the service if you bill 98960, as some payers are clear they won’t reimburse 98960 for physician services. “Physicians who provide genetic counseling, health and behavior assessment/intervention, medical nutrition therapy or education and training for patient self-management should report these services using evaluation and management codes,” states UnitedHealthcare national guidance on 98960.