Billing for Patient Education How to Make Money

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

Introduction Presenters Audience

Overview l Exam Room – Evaluation and Management Codes l Population – quality based purchasing and disease management l 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 – 99499 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. l Vitals and Lung exam WNL l Asthma – controlled – refill albuterol and Azmacort l

E/M Code for Case Scenario #1 99212

Alphabet Soup l 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 l RVU –Relative Value Unit l

E and M Codes Established Patient E & M 99211 Code Type of Simple visit 5 min RVU’s 0. 55 99212 $$$ 38. 65 20. 84 99213 99214 99215 Simple Low Mod High 10 min 15 min 25 min 40 min 1. 02 1. 66 2. 52 3. 42 62. 91 82. 14 119. 11

E and M Codes New Patient E&M Code Type of Visit RVU’s 99201 $$$ 36. 22 99203 99204 99205 Simple Low Moder High 10 min 20 min 30 min 45 min 60 min 0. 99 1. 73 2. 56 3. 92 4. 93 64. 59 95. 96 135. 53 172. 12

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 l 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 l Vitals and Lung exam WNL. l Asthma – improper use of medications – counseled on proper use of rescue/maintenance meds and trigger controls. l

E and M code for Case Scenario #2 l 99213

E and M Code for Case Scenario #3 l 99214

Health Maintenance Visits and Prevention Codes

Health Maintenance Visits and Prevention Codes l Age and gender specific risk reduction education, cancer screening, immunization, etc. – USPSTF l Template driven notes helpful l 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 99391 99392 99393 99394 99395 99396 99397 Code Age <1 1 -4 5 -11 12 -17 18 -39 40 -64 >65 RVU 2. 04 2. 28 2. 26 2. 49 2. 51 2. 77 3. 07 $$$ 77. 31 $86. 40 $85. 65 $94. 36 $95. 12 $104. 98 $116. 34

Prevention Codes – New Patients E/M 99381 99382 99383 99384 99385 99386 99387 Code Age <1 1 -4 5 -11 12 -17 18 -39 40 -64 >65 RVU 2. 61 2. 82 2. 78 3. 02 3. 54 3. 85 $$$ 98. 91 106. 87 105. 35 114. 45 134. 16 145. 90

Medicare and Preventive Service Codes l Welcome to Medicare exam – G 0344 (2. 57 RVU - $97. 00) l One time only for new Part B beneficiaries l Within six months of enrollment l Must include EKG – G 0367 – EKG tracing – G 0368 – EKG interpretation and report

Tobacco Cessation Counseling and Medicare

Tobacco Cessation Counseling Medicare l Tobacco use + chronic condition l Two quit attempts allowed per year l Four counseling sessions per attempt l Use modifier 25 if done with E/M visit l Classification of counseling sessions: – Intermediate – 3 to 10 minutes (G 0375 – 0. 34 RVU - $12. 00) – Intensive – > 10 minutes ( G 0376 – 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 l Code and bill l l l

Billing for Group Visits l CPT code 99499 – “unlisted evaluation and management service” – many payers do not reimburse for this code l CPT E/M codes based on documentation l Bottom line – check with your individual payers

Population Quality Based Purchasing l Disease Management l

CPT Overview Evaluation and Management 99211 – 99214 (E/M) **** 99201 - 99204 Case Management Medical Nutrition Therapy (MNT) **** Diabetes Self Management Training (DSMT) **** Disease Management (Asthma, Youth in Motion) 99361, 99362 Team conf 99371, 99372 Phone 97802 - 97804 G 0108 G 0109 99401 -99404 counseling - I 99411 -99412 counseling -G 99420 Health Risk Profile

Disease Management l l Contract deliverables with third party payer (Ex. CFHP) Monthly/quarterly reports – Number of visits by member – Outcomes data – Patient satisfaction data l l Periodic team meetings with third party payer Longitudinal program – Administration and interpretation of Health Risk Assessment (99420) – Individual counseling (99401 -15 min, 99402 -30 min, 99403 -45 min, 99404 -60 min) – Group counseling (99411 – 30 minutes, 99412 – 60 minutes) – Phone visits (99371 -99372) – Education material

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

Medical Nutrition Therapy (MNT) 97802 Initial, Individual 15 minutes (diabetes – 3 hours) 0. 85 RVU $32. 21 Per 15 min 97803 Reassessment, Individual 15 minutes (diabetes – 2 hours/year) 0. 76 RVU $28. 80 Per 15 min 97804 Group 30 minutes 0. 41 RVU $15. 54 per 30 min

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

Diabetes Self-Management Training (DSMT) l Eligibility criteria – New onset diabetes within 12 months – Diabetes out of control with 2 consecutive Hgb. A 1 c > 8. 5% l Initial DSMT 10 hours to be provided within 12 months (one time only) l Follow-up DSMT upto 2 hours (annually)

Diabetes Self-Management Training (DSMT) G 0108 G 0109 Individual - diabetes self management training/case management and/or risk factor reduction intervention. (3 hours recommended) Group - diabetes self management training/case management and/or risk factor reduction intervention. (10 hour course) 0. 78 RVU $29. 56 per 30 minutes 0. 45 RVU $17. 05 per 30 minutes

Case Management Services Telephone Calls 99371 Simple/Brief By physician to coordinate care with HC team. Adjust therapy. $16. 00 99372 Intermediate – $42. 00 Initiate therapy on Est pt on new problem, start new plan

Case Management Services Team Conferences 99361 30 minutes By a physician with team to coordinate care. $105. 00 99362 One hour By a physician with a team to coordinate care. $185. 00