Time Is Money

October 1, 2003

Advice on getting paid for extra services

Physicians are nice people. They want to do more than treat disease. They believe in prevention and patient empowerment.
Unfortunately, the healthcare payment system doesn't have the same sense of benevolence.

For example, physicians who teach patients to manage chronic diseases or to improve their nutrition usually don't get reimbursed for their proactive approach.

In many cases, payers simply aren't set up to pay for such services -- even though they may judge the quality of a physician group based on whether they provide them. In other cases, they simply consider them part of what they expect any physician to do as part of services they do pay for.

Not getting paid is no reason, of course, to give up going the extra mile. But it sure is depressing.

Here is our mood-lifter -- the best advice we could find on getting paid for providing these so-called "extra" services.

Patient education

A well-informed patient is a better, and usually healthier, patient. But most insurers simply expect patient education to occur during the course of an office visit, and won't pay extra for it.

For example, there is a CPT code for educational supplies, such as books or pamphlets, that physicians provide out of their own pockets -- 99071. However, almost no payers, including Medicare, actually pay for the code.

If you want to be reimbursed for such items, you could ask payers about having their beneficiaries cover the cost of the materials directly. This is not permissible for Medicare beneficiaries, however. It may also be worth your while to cover the cost yourself, if it cuts down on the number of follow-up calls and other unbillable activities you are forced to handle.

Patient education also can mean counseling patients about their risk factors -- working on smoking cessation or weight control, for example. How you bill for these counseling services depends on whether they are connected to a specific diagnosis or are preventive in nature.

The V65 series ICD-9 codes might apply to counseling done for a specific disease state. Code V65.3, for example, is specific to "dietary surveillance and counseling," including eight risk factors such as diabetes, obesity, colitis, food allergies, and gastritis, and could be coded with an appropriate E&M code -- often 99211 since nurses frequently do the counseling.

Also consider codes 99401 to 99404. These codes are for preventive medicine and individual counseling, respectively, and can't be used for "interventions provided to patients with symptoms or established illness," according to the CPT description. "For counseling individual patients with symptoms or established illness, use the appropriate office, hospital or consultation, or other E&M codes."

Whatever code you use, be aware that many Medicare carriers and private payers don't reimburse for these codes, even if billed.
Some physicians decide to offer smoking cessation seminars or weight control visits anyway, asking patients to pay for them out-of-pocket. Be careful if you like that idea. Some managed-care contracts stipulate that such instruction is part of the basic E&M service. And even if you decide you can charge patients directly after contacting payers or reviewing your contracts, it's prudent to have the patient sign an acknowledgment of liability for noncovered services before the session begins. You want patients to know in advance that they have to pay for it.

Diabetes training

There is no doubt that a diabetic patient who understands how to self-manage will have better outcomes than a patient who doesn't understand the dynamics of the disease. And Medicare, at least, will reimburse for the time you spend on outpatient diabetes education, but there are some very particular rules to follow:


The training has to be ordered by a "qualified" physician or nonphysician practitioner. Patient self-referral is not allowed and nonphysicians have to be acting within their scope of practice. "Qualified" means the physician or other caregiver has met specific quality standards. For more details on how to qualify, go to www.access.gpo/su_docs/fedreg/a001229c.html and scroll down to the section from the Health Care Financing Administration, or e-mail us at info@physicianspractice.com for a copy of the document.

The bottom line is that you can't simply start billing for diabetes education; you have to prove your qualifications to the satisfaction of the Centers for Medicare and Medicaid Services (CMS). In addition:

  • The physician (or midlevel) has to prepare a care plan that includes the content, number, frequency, and duration of the training.
  • The provider must determine if  the diabetes self-management training is reasonable and necessary for the treatment of the beneficiary's diabetes.
  • The services must be furnished in a group setting of two to 20 (unless the patient's disease makes it impossible for some reason). 

 The Medicare beneficiary also has to meet some requirements. According to CMS, to qualify for the benefit the patient has to have:

  • New-onset diabetes
  • Poor glycemic control as evidenced by a glycosylated hemoglobin (HbA1C) of 9.5 percent or more in the 90 days before attending the training.
  • A change in treatment regimen from no diabetes medications to any diabetes medication, or from oral diabetes medication to insulin.
  • High risk for complications based on poor glycemic control, as documented by acute episodes of severe hypoglycemia in the past year during which the beneficiary needed third party assistance for either emergency room visits or hospitalization.
  • High risk based on at least one of the following documented complications:
     - Lack of feeling in the foot or other foot complications such as foot ulcer or amputation.
     - Pre-proliferative or proliferative retinopathy or prior laser treatment of the eye.
     - Kidney complications related to diabetes, such as macroalbuminuria or elevated creatinine.

Assuming all these conditions are met, Medicare will pay for up to 10 hours of initial self-management training over a 12-month period or one hour of follow-up training per year, if warranted.

You would bill Medicare with one of these HCPCS codes:

  • G0108: Diabetes outpatient self-management training services, individual, per 30 minutes, or
  • G0109: Diabetes self-management training services, group session (2 or more), per 30 minutes.

Medicare's payment for those 30 minutes is 0.49 RVUs in 2003 or about $18, though that will vary somewhat depending on where you work.

Also, many payers recognize medical nutrition therapy codes (97802-97804) for diabetic educational counseling. You'll need to contact your payers to clarify their policies.

Family matters

Some physicians also struggle to bill for the time they spend working with the family members of sick -- often elderly -- patients. If a physician spends an hour with the daughter of a patient with dementia, can she bill for it? And under whose plan? The daughter's? The patient's?

For Medicare, at least, physicians can bill for counseling family members under the patient's name even if the patient is not present.
Most carriers follow Medicare's rules but you'll want to double-check. Here are Medicare's rules regarding coding for a visit without the patient's presence:

"Family counseling services are covered only where the primary purpose of such counseling is the treatment of the patient's condition. For example, two situations where family counseling services would be appropriate are as follows:
(1) [W]here there is a need to observe the patient's interaction with family members; and/or
(2) [W]here there is a need to assess the capability of, and assist the family members in, aiding in the management of the patient.
Counseling principally concerned with the effects of the patient's condition on the individual being interviewed would not be reimbursable as part of the physician's personal services to the patient."

Further, the American Medical Association's official coding book, Principles of CPT Coding, Second Edition, suggests, "Family members may indeed receive counseling from the physician without the patient being present. Counseling of family members alone is reported with the various levels of E/M service."

Filling out forms

There are CPT codes for forms -- 99080 for filling out special reports, like insurance forms, and 99455-99456 for disability forms. The codes specifically indicate that an E&M service performed by the physician is included in the service; they are not just for staff time. Regardless, very few insurance carriers will actually pay you for the codes.

Some practices opt to charge patients a handling fee to cover the administrative expenses associated with these forms. Most practices that charge (and most still don't, although it's a growing trend) charge $5 to $10.

However, Medicare does not allow physicians to charge for filling out claim forms, so if you participate in Medicare, you cannot charge those patients. Also, some commercial payers expressly forbid fees like this; check your contracts.

Moreover, as a courtesy to your patients and to protect yourself, inform your patients in advance and in writing that you charge for this service. You might include this information in your financial policy.

Coordinating care


There are two sets of codes for coordinating care: "case management services" and "care plan oversight services."
Case management codes (99361, 99362, 99371, 99372) apply when a physician coordinates, controls access to, initiates, or supervises other healthcare services needed by a patient she sees directly.

Care plan oversight codes (99374, 99377, 99379) cover recurrent, frequent and high-intensity supervision of patients in home, hospice, and nursing facility care.

Be sure to review the full descriptions of each of these codes to see if they apply to the services you provide.

After-hours care

What about those special Saturday or late-weekday hours? If services are provided during regular operating hours -- whether those are from 8 a.m. to 4 p.m. Monday through Friday or 9 a.m. to noon on Saturday -- they have to be coded and reimbursed in the same, standard manner. That is, if you have regular hours after 5 p.m. or on the weekends, even if those times are reserved for urgent visits only, you can't code visits during those times as after-hours visits. The fact that the appointment is made after 5 p.m. does not automatically make it "after office hours."

That said, there are some after-hours codes:

  • 99050: Services requested after office hours in addition to basic service.
  • 99052: Services requested between
    10 p.m. and 8 a.m. in addition to basic service.
  • 99054: Services requested on Sundays and holidays in addition to basic service.

Again, all these codes require a service that is above and beyond the usual, basic service, so they do not apply to normal Saturday or extended hours. They also don't apply to hospital call; they are only for physician office use.

While billing for these services isn't always a straightforward
process, remember that being a nice guy and going the extra mile for your patients can pay off in greater job satisfaction and better patient health, even if it doesn't pay off in accounts receivable.

Pamela Moore, PhD, senior editor for Physicians Practice,  can be reached at pmoore@physicianspractice.com.

This article originally appeared in the October 2003 issue of Physicians Practice.