Carolyn Buppert NP, JD


February 06, 2008

Response from Carolyn Buppert NP, JD


Carolyn Buppert NP, JD
Attorney, Private Practice, Bethesda, Maryland

Currently, most insurers and health plans do not reimburse individual nurse practitioners (nor physicians) for group education. While there is a procedure code for group education -- 99078, most payers do not reimburse for that code. A provider of Diabetes Self-Management Education (DSME) -- a hospital, clinic or physician office -- may bill for DSME provided by a Certified Diabetes Educator (CDE), if the entity meets the certification requirements of the American Diabetes Association. DSMT is a program that includes instruction in self-monitoring of blood glucose, education about diet and exercise, an insulin treatment plan developed specifically for the patient who is insulin-dependent, and motivation for patients to use the skills for self-management. The DSME provider must provide all aspects of the DSME service. The provider bills G0109 for each 30 minutes. According to Medicare's fee schedule for Dallas, Texas, for example, the nonfacility reimbursement is $18.14 for G0109. There is no reimbursement listed for a facility.

Currently, the NP's (and physician's) role in the process of diabetes education is generally twofold. First, the NP may conduct one-to-one education and counseling in the office and may bill an Evaluation/Management code for that service. Second, the NP or physician may certify that the patient needs DSME -- order the DSME -- and the patient is sent to a center qualified to perform DSME. For a DSMT provider to get paid, the provider must have a referral from a physician or qualified non-physician practitioner (such as an NP). There is a possible third role, and that is for an NP to become a Certified Diabetes Educator, working within a DSME program.

Some experts recommend that physicians bill procedure code 99499 ("unlisted evaluation and management service") when performing group education. However, most payers don't reimburse for that code.

So, until payers are convinced of the value of group education, the most efficient use of an NP's time is at the level of the one-to-one patient visit. A practice could schedule group instruction and have an NP or physician conduct one-to-one visits before or after the group education, and bill for an evaluation/management office visit for each patient, if the requirements of the procedure codes for office visits -- history, physical examination, and medical decision-making -- are met.


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