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Reimbursement Getting Paid for What You Do. Enhancing Reimbursement: What do You Need to Know? Types of health plans and differences Authorization process.

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Presentation on theme: "Reimbursement Getting Paid for What You Do. Enhancing Reimbursement: What do You Need to Know? Types of health plans and differences Authorization process."— Presentation transcript:

1 Reimbursement Getting Paid for What You Do

2 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

3 OVERWHELMING? YES!!!

4 Types of Health Plans Fee for Service HMO (managed care) Medicaid/Medi-Cal (CPSP) Medi-care

5 CODING 101 ICD-9,CPT-4 Codes, HCPCS, E/M, DMST/MNT

6 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

7 You must document and code both for each client you see to get reimbursed!

8 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

9 2010 ICD-9 Specific Codes The entire code 648 is listed as ”complications of pregnancy, childbirth, or the puerperium” is diabetes mellitus complicating pregnancy, childbirth, or the puerperium

10 Diabetes mellitus of mother with delivery This is a code that can be used to specify a diagnosis

11 Diabetes mellitus of mother with delivery with postpartum complications

12 Antepartum diabetes mellitus The state of pregnancy in women with pre- existing diabetes mellitus Does not include GDM is a specific code that can be used to specify a diagnosis

13 Postpartum Diabetes Mellitus Can be used to specify a diagnosis

14 (+ 1 digit) is abnormal glucose tolerance of mother complicating pregnancy, childbirth, or the puerperium Unspecified as to episode of care

15 It can be used to specify a diagnosis is abnormal glucose tolerance of mother antepartum GDM

16 is abnormal glucose tolerance of mother postpartum It can be used to specify a diagnosis

17 Specificity and accuracy are the keys to successful billing!

18 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

19 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

20 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

21 “Qualified” Providers of Diabetes Education Certified Diabetes Educator Physician Clinical Psychologist Clinical Social Worker Nurse Midwife Nurse Practitioner Physician’s Assistant Registered Dietitian

22 CPT Codes for Diabetes Supplies CPT codes are also used for billing diabetes testing & injection supplies

23 Medicare “G” Codes Diabetes Self-management Education/Training (DSME/T) individual or group Medical Nutrition Therapy (MNT) Limited number of visits

24 Evaluation & Management Codes (E/M) Outpatient services Initial Consultation New patients 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

25 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

26 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) PPO plan (fee for service) Initial - Length of Visit 1-1/2 hours CPT Codes: Initial Outpatient Service (60 min) Initial Consultation (80 min) Initial Assessment and Intervention for MNT (15 min each) One time fee for case coordination between care givers, referrals, etc.

27 GDM Diet Follow-Up Service Description In 1 week Assess care plan, diet, weight gain, adjust diet, exercise, meds as needed ICD antepartum ICD postpartum Follow-Up – Length of Visit MNT Reassessment and Intervention (15 min each) F/U Outpatient Service (25 min each) 1 hour

28 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: Initial Outpatient Service (60 min) Initial Consultation (80 min) Initial Assessment and Intervention for MNT (each 15 min increment) One time fee for case coordination between care givers, referrals, etc.

29 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: MNT Reassessment and Intervention (15 min each) F/U Outpatient Service (25 min each)

30 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: Initial Outpatient Service (60 min) Initial Consultation (80 min) Initial Assessment and Intervention for MNT (15 min each) One-time fee for case coordination between care givers, referrals, etc.

31 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: MNT Reassessment and Intervention (15 min each) F/U Outpatient Service (25 min each)

32 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: MNT Reassessment and Intervention (15 min each) F/U Outpatient Service (15 min each)

33 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: Initial Outpatient Service (60 min) Initial Assessment and Intervention for MNT (15 min each) One time fee for case coordination between care givers, referrals, etc.

34 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: MNT Reassessment and Intervention (15 min each) F/U Outpatient Service (15 min each)

35 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: Initial Outpatient Service (60 min) Initial Consultation (80 min) Initial Assessment and Intervention for MNT (15 min each)

36 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: Initial Outpatient Service (60 min) Initial Consultation (80 min) Initial Assessment and Intervention for MNT (15 min each) One time fee for case coordination between care givers, referrals, etc.

37 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: MNT Reassessment and Intervention (15 min each) F/U Outpatient Service (25 min each)

38 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: MNT Reassessment and Intervention (15 min each) F/U Outpatient Service (15 min each)

39 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: F/U Outpatient Service (15 min each) or F/U Outpatient Coordination of Care with other providers or agencies MNT Reassessment and Intervention (each 15 min.) One time fee for case coordination between care givers, referrals, etc.


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