Ask the Expert

This month’s selection:
We have an endocrinologist on staff who wants to start management training for her diabetic patients. I am not finding that many insurance carriers cover the CPT code 98960, Education/training patient for self-management. Medicare is reimbursing for G0108, Diabetes self-management/individual, and G0109, DSMT, 2 or more. Now that Medicare is recognizing this care, is there a reason commercial insurance carriers are not embracing this self-management for diabetes patients? Is there another code I should be using?

Darlene Earl, CCS-P
Tallahassee Primary Care Associates
Tallahassee, Fla.

Response:
It’s nice that Medicare does pay for this, but commercial carriers don’t have to do anything they don’t want to.

I’d recommend taking the issue to the facility’s contract management department and encourage them to aggressively negotiate their next contract with commercial carriers to include coverage of services/codes that are covered by Medicare—especially if they can convince them to pay better than Medicare!

This type of effort will be more successful if they can show reduced readmission rates or a lower number of visits for diabetes diagnoses in patients who have had the self-management training. Most businesses want to know “what’s in it for me?” If you can show that a little expense now reduces big expenses later, they’ll be more likely to begin covering preventative services like this one.

— Judy Sturgeon, CCS, CCDS, is the clinical coding/reimbursement compliance manager at Harris County Hospital District in Houston and a contributing editor at For The Record. While her initial education was in medical technology, she has been in hospital coding and compliance for 21 years.