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Reimbursement/Coding. THE INFORMATION REGARDING REIMBURSEMENT IS PROVIDED FOR INFORMATIONAL PURPOSES ONLY AND REPRESENTS NO STATEMENT, PROMISE, OR GUARANTEE.

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Presentation on theme: "Reimbursement/Coding. THE INFORMATION REGARDING REIMBURSEMENT IS PROVIDED FOR INFORMATIONAL PURPOSES ONLY AND REPRESENTS NO STATEMENT, PROMISE, OR GUARANTEE."— Presentation transcript:

1 Reimbursement/Coding

2 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.

3 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

4 Coding for SMA What determines the 4 th digit? What determines the 5 th digit? What education code is used? How long does the education have to be? What CPT code is most likely?

5 Diabetes Coding BasecodeManifestations Add as 4th digit CompleteCode 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 250None0250.0X1302 250Renal4250.4X1302 250Ophthalmologic5250.5X1302 250Neurological6250.6X1302 250 Peripheral Circulatory 7250.7X1302 250 Other specified 8250.8X1302 250Unspecified9250.9X1302 Gestational Diabetes 648.03 Example: Code diabetes first: 250.XX Code also manifestation: 250.5 Retinopathy

6 Coding for SMA 4 th digit? Complications/manifestations 5 th 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

7 DSME and MNT Complimentary BOTH 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

8 Avoiding paybacks

9 Pt Completed/Provider Reviewed Nurse and Provider Completed Quick, Simple and Scan it!

10 SMA: E/M Visit Aver. # pts seen10 # 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

11 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

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