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Coding Consult: When the patient has diabetes


Stay sharp when coding your visits with diabetic patients.


Coding Consult

When the patient has diabetes

Jump to:
Choose article section...Get paid for education Code for training during an office visit Differentiate between education and MNT


A diagnosis of diabetes affects coding for services ranging from preventive care visits to treating the flu. Stay on top of your diabetes coding game; it could affect your bottom line. There are three common encounters with your diabetic patients:

• Routine appointments to monitor the effectiveness of treatment. These visits should not be mistaken for preventive services. Report the appropriate office visit code, such as 99213 (office or other outpatient visit for the E&M of an established patient), not a preventive medicine services code such as 99395.

• Problem-focused care of the diabetes provided during a bonafide preventive visit. For example, if a 60-year-old woman is seen for her annual checkup and, during the course of the visit, you also evaluate her diabetes, both the preventive service and the appropriate problem-focused E&M service should be reported. Append modifier –25 (significant, separately identifiable E&M service by the same physician on the same day of the procedure or other service) to the E&M service to indicate that it was separate from the preventive service rendered at the same patient encounter.

• Problem-focused visits that may be complicated by the diabetes. When a diabetic presents with symptoms of another illness, such as a sore throat, you need to spend extra time assessing how the two conditions relate. This extra time often includes additional consideration during the history and exam components of the E&M service as well as adding complexity to the medical decision-making component. The result: You may be able to report a higher level of E&M service.

Get paid for education

Educating patients with diabetes on proper self-care can be time-consuming, and so can trying to get paid. Did you know that you should be reporting E&M codes for your services?

Diabetes self-management training programs help patients manage their glycemic control; perform daily self-care and self-monitoring; and balance nutrition, exercise, and medicine.

You can receive compensation for training patients with diabetes who are newly eligible for Medicare. For other beneficiaries to be covered for initial training, Medicare specifies the following medical conditions:

• New onset diabetes.

• Inadequate glycemic control as evidenced by a glycosylated hemoglobin (HbA1C) level of 8.5 percent or more on two consecutive HbA1C determinations three or more months apart in the year before the beneficiary begins receiving training.

• A change in treatment regimen from diet control to oral diabetes medication, or from oral diabetes medication to insulin.

• High risk for complications based on inadequate glycemic control (documented acute episodes of severe hypoglycemia or acute severe hyperglycemia occurring in the past year during which the beneficiary needed emergency room visits or hospitalization).

• High risk based on at least one of the following: lack of feeling in the foot, or other foot complications such as foot ulcers, deformities, or amputation; preproliferative or proliferative retinopathy or prior laser treatment of the eye; or kidney complications related to diabetes, when manifested by albuminuria, without other cause, or elevated creatinine.

"Diabetes outpatient self-management services are covered by Medicare only if you or a qualified nonphysician practitioner who is managing the beneficiary's diabetic condition certifies that services are needed. Send an original referral form to the diabetes education program," says Bruce Rappoport, an internist with RCH Healthcare Advisors in Fort Lauderdale.

The referral must be done under a comprehensive plan of care related to the beneficiary's diabetic condition to ensure therapy compliance or to provide the individual with necessary skills, such as the self-administration of injectable drugs. Specific coverage requirements can be found in the Code of Federal Regulations at 42 CFR 410.140-146 or in the Federal Register Vol. 65, No. 251, 12/29/00, p. 83130.

Code for training during an office visit

There are different rules and coding guidelines for reporting diabetes education provided during office visits.

"If you spend more than half of a session educating a patient one-on-one, document the appropriate E&M codes based on time," says Mary Falbo, president of Millennium Healthcare Consulting in Lansdale, PA.

For example, a new patient presents with new onset diabetes. You perform the required history, exam, and medical decision-making component of a new patient office visit. Then you turn to counseling the patient on managing her diabetes, documenting the content of the counseling session. You report spending 30 minutes with the patient, 17 of which were spent discussing the diabetes management recommendations. The 17 minutes constitute greater than 50 percent of the exam, so you can bill the visit based on time, Falbo says.

How you report the services of American Diabetes Association-certified training providers depends on whether the patient is covered by Medicare or by a third-party payer. According to CMS, a "certified provider" is "a physician or other individual or entity designated by the Secretary that, in addition to providing diabetes outpatient self-management services, provides other items or services for which payments may be made . . . such as medical services or durable medical equipment, and meets certain quality standards."

"If, for example, a nurse has received a certificate of recognition from the ADA indicating that he or she meets the National Standards for Diabetes Self-Management Education Programs, the nurse's training services can be billed," Rappoport says.

If the patient is covered by Medicare and meets Medicare's required medical indications, and the person providing the education is a certified provider, you can bill for the self-management training with G0108 (diabetes outpatient self-management training services, individual, per 30 minutes) and G0109 (diabetes self-management training services, group session [2 or more], per 30 minutes).

Some commercial carriers cover code 99078 (physician educational services rendered to patients in a group setting [e.g., prenatal, obesity, or diabetic instructions]) for providing education when the program is not certified.

Remember, the training must be ordered by you or another qualified provider, and the order must be part of a comprehensive plan of care. Include a statement that indicates the service is needed.

For more information regarding the requirements for initial and follow-up sessions of outpatient diabetes self-management training, see CMS Program Memorandum Transmittal B-01-40 available on the CMS Web site, trans/B0140.pdf .

Differentiate between education and MNT

A source of confusion when reporting diabetes education services is the different requirements for reporting medical nutrition therapy (MNT) for Medicare patients, Falbo says.

MNT zeroes in on how nutritional adjustments play a role in managing patients with diabetes or renal disease that does not require dialysis, the key qualifier for Medicare, Falbo says. Unlike diabetes self-management training, of which Medicare patients can receive a maximum of 10 hours per year, Medicare patients can receive up to three hours of MNT for the first year, and two additional hours in subsequent years with a referral from the treating physician. Referrals for MNT can't be made by a nonphysician practitioner.

Unlike self-management training, "you can't bill Medicare for MNT services," Falbo emphasizes. "This is only for registered dietitians and nutrition professionals."

They can expect to be reimbursed 85 percent of the fee allotted in the Medicare Physician Fee Schedule Database for:

• 97802 (MNT, initial assessment and intervention, individual, face to face with the patient, each 15 minutes)

• 97803 (MNT, reassessment and intervention, individual, face to face with the patient, each 15 minutes) or

• 97804 (. . . group, each 30 minutes).

The new G codes are used when there's a change in the beneficiary's condition: G0270 (MNT, reassessment and subsequent intervention[s] following second referral in same year for change in diagnosis, medical condition or treatment regimen [including additional hours needed for renal disease], individual, face to face with the patient, each 15 minutes) and G0271 (. . . group, each 30 minutes).


This information provided by The Coding Institute. For a free sample issue or information on how to subscribe to any of 29 specialty-specific coding newsletters, please contact The Coding Institute, 2272 Airport Road South, Naples, FL 34112; phone 800-508-2582; fax 800-508-2592; or visit


Coding Consult: When the patient has diabetes. Medical Economics Aug. 8, 2003;80:17.

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