Billing for Patient Education: How to Make Money for Your Practice By Priti Mody-Bailey, MD, MA Rebecca Jaffe, MD

Introduction Presenters Audience

Overview Exam Room – Evaluation and Management Codes Population – quality based purchasing and disease management Community – Healthfairs and media

Exam Room Routine Office Visits – Counseling time and E/M Codes Health Maintenance Visits – Preventive Medicine Codes Tobacco Cessation Counseling and Medicare Group Visits – and E/M Codes

Routine Office Visit and E/M Codes

Case Scenario # 1 32 y/o male present for f/u of asthma – states doing well. Vitals and Lung exam WNL Asthma – controlled – refill albuterol and Azmacort

E/M Code for Case Scenario #

Alphabet Soup HCPCS (Hick-Picks) Healthcare Common Procedure Coding System CPT – Current Procedural Terminology E and M – Evaluation and Management Codes ICD 9 – International Classification of Diseases RVU –Relative Value Unit

E and M Codes Established Patient E & M Code Type of visit Simple 5 min Simple 10 min Low 15 min Mod 25 min High 40 min RVU’s $$$

E and M Codes New Patient E & M Code Type of Visit Simple 10 min Simple 20 min Low 30 min Moder 45 min High 60 min RVU’s $$$

Time Guidelines “where counseling and/or coordination of care dominates (more than 50%) the face-to-face physician/patient and/or family encounter, then time is considered the key or controlling factor for a particular level-of-service.” * Document total face-to-face time * Describe the counseling and/or activities to coordinate care Consider stating the estimated time spent in counseling

Appropriate Counseling “Counseling and/or coordination of care with other providers or agencies consistent with the nature of the problem and the patient’s and/or family’s needs.”

Appropriate Counseling Discussion with the patient and/or family concerning one or more of the following: – Diagnostic results, impressions and/or recommended studies – Prognosis; risks and benefits of management/treatment options – Instructions for management/treatment or follow-up – Importance of compliance with chosen management options – Risk reduction – patient and family education

Case Scenario #2 and #3 32 y/o male comes in for f/u on asthma – doing well overall. Using albuterol twice a day every day and Azmacort in emergency. Has a cat at home Vitals and Lung exam WNL. Asthma – improper use of medications – counseled on proper use of rescue/maintenance meds and trigger controls.

E and M code for Case Scenario #

E and M Code for Case Scenario #

Health Maintenance Visits and Prevention Codes

Age and gender specific risk reduction education, cancer screening, immunization, etc. – USPSTF Template driven notes helpful Not all payers pay for prevention codes – Medicare pays for this but very specific rules - check with your local payers

Prevention Codes for Established Patient E/M Code Age < >65 RVU $$$ 77.31$86.40$85.65$94.36$95.12$104.98$116.34

Prevention Codes – New Patients E/M Code Age < >65 RVU $$$

Medicare and Preventive Service Codes Welcome to Medicare exam – G0344 (2.57 RVU - $97.00) One time only for new Part B beneficiaries Within six months of enrollment Must include EKG – G0367 – EKG tracing – G0368 – EKG interpretation and report

Tobacco Cessation Counseling and Medicare

Tobacco Cessation Counseling Medicare Tobacco use + chronic condition Two quit attempts allowed per year Four counseling sessions per attempt Use modifier 25 if done with E/M visit Classification of counseling sessions: – Intermediate – 3 to 10 minutes (G0375 – 0.34 RVU - $12.00) – Intensive – > 10 minutes ( G0376 – 0.67 RVU - $25.00)

Group Visits A change from regular office visits Decide on a topic Identify the population Have a confidentiality statement Formulate a check-mark progress note Review record prior to the visit Administer a patient satisfaction survey Develop an agenda – time for patient education and time for one-on-one visit Code and bill

Billing for Group Visits CPT code – “unlisted evaluation and management service” – many payers do not reimburse for this code CPT E/M codes based on documentation Bottom line – check with your individual payers

Population Quality Based Purchasing Disease Management

CPT Overview Evaluation and Management (E/M) **** – Case Management99361, Team conf 99371, Phone Medical Nutrition Therapy (MNT) **** Diabetes Self Management Training (DSMT) **** G0108 G0109 Disease Management (Asthma, Youth in Motion) counseling - I counseling -G Health Risk Profile

Disease Management Contract deliverables with third party payer (Ex. CFHP) Monthly/quarterly reports – Number of visits by member – Outcomes data – Patient satisfaction data Periodic team meetings with third party payer Longitudinal program – Administration and interpretation of Health Risk Assessment (99420) – Individual counseling ( min, min, min, min) – Group counseling (99411 – 30 minutes, – 60 minutes) – Phone visits ( ) – Education material

Medical Nutrition Therapy (MNT) Part B Medicare Benefit (January 1, 2002) Dietician/Nutrition professional – Medicare provider Eligibility – Diabetes – Chronic renal insufficiency – Post successful transplant Provider using nationally recognized protocols (ADtA –

Medical Nutrition Therapy (MNT) 97802Initial, Individual 15 minutes (diabetes – 3 hours) 0.85 RVU $32.21 Per 15 min 97803Reassessment, Individual 15 minutes (diabetes – 2 hours/year) 0.76 RVU $28.80 Per 15 min 97804Group 30 minutes 0.41 RVU $15.54 per 30 min

Diabetes Self-Management Training (DSMT) Medicare – effective February 27, 2001 Meet standards specified in the National Standards for DSMT Accredited by one of below organizations – ADA Education Recognition Program ( – Indian Health Services (Fed Reg 3/22/02)

Diabetes Self-Management Training (DSMT) Eligibility criteria – New onset diabetes within 12 months – Diabetes out of control with 2 consecutive HgbA1c > 8.5% Initial DSMT 10 hours to be provided within 12 months (one time only) Follow-up DSMT upto 2 hours (annually)

Diabetes Self-Management Training (DSMT) G0108Individual - diabetes self management training/case management and/or risk factor reduction intervention. (3 hours recommended) 0.78 RVU $29.56 per 30 minutes G0109Group - diabetes self management training/case management and/or risk factor reduction intervention. (10 hour course) 0.45 RVU $17.05 per 30 minutes

Case Management Services Telephone Calls 99371Simple/Brief - By physician to coordinate care with HC team. Adjust therapy. $ Intermediate – Initiate therapy on Est pt on new problem, start new plan $42.00

Case Management Services Team Conferences minutes By a physician with team to coordinate care. $ One hour By a physician with a team to coordinate care. $185.00