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Implementing a Diabetes Management Program in a Community Pharmacy: Part 3 of 3

by Dr. Michael Case Haub


Once you are IDPH certified you should be able to bill for insurances in Iowa (Medicaid too). By the way, you are already a PCM provider for Iowa Medicaid, aren't you? Once you become ADA recognized, you should be able to bill Medicare for any eligible patients.


You will have to decide how you are going to bill for services. There are different options, such as patients pay upfront, reimbursed from you, reimbursed from insurance, accept assignment, etc. I would look at your main payers in your region before setting a price. In our region, these payers are Medicaid, Medicare, UHC, Aetna, and Wellmark.


Keep in mind that you cannot bill a patient for any amount over a contracted price. For example, you charge $1000/patient for your diabetes education series but Wellmark only pays you $650 (contracted price). That is it; you are not allowed to bill the patient for the difference ($350). But if Wellmark rejects a claim the patient can be billed for the full amount. I recommend having patients sign a consent form for situations such as this.


Let's discuss how to bill. I suggest getting a National Provider ID (NPI) number first. This web address can help you with that process: http://nppes.cms.hhs.gov. You will most likely get another number from each insurer initially but ultimately all insurers will have to use NPI (May 27, 2007).


It is also a good idea to contact the insurance company for information. You will want to know how to become a provider (contracted or non- contracted). It is helpful to have studies available to send insurances about positive impact pharmacist interventions have on outcomes & decrease costs. Remember this is a medical claim not a pharmacy claim. Remember to ask about details such as, the type of billing format they accept whether by hardcopy or electronic. (Paper- by hand, www.ezclaim.com, pharmacy dispensing system, insurance's website, free software or other clearinghouse)


Of the different billing options, electronic claims are faster and have quicker reimbursement, but may be more costly to initiate. If you have a DME contract with a company they may consider having you bill with that ID number. You may also have to bill with your Tax ID number. Be persistent, you may even have to fax a copy of Iowa Diabetes Legislation: Senate File 8 to prove that once certified, insurances (in Iowa) have to recognize you as a provider of diabetes education.


You might be able to bill for diabetes related point- of-care testing with your ID number or you may have to be recognized as a laboratory. I have become a laboratory provider in the past and it was not an easy task! As a reminder, you need to have a physician sign off on your diabetes education protocol. Consider any testing and physical assessments you would want to do during your education and monitoring and be sure to incorporate that into your protocol.


When you begin billing, use a CMS 1500 form (or similar electronic format). If you are paper billing, consider adding other documentation with bill, such as a superbill, Pharmacist Care Claim Form, etc. to explain exactly what services were provided. Remember “Document, document, document!”


You should be familiar with all of the sections that need to be filled out. You might have a PIN number or you might have to put your ID in “reserved for local use space.” Remember to fill in “referring physician” as the actual referring physician of a patient. Also, pharmacy is now “Place of Service” and that code is = 01. “Type of Service” codes you will most likely use are 01= medical services; 03= consultations; 05=laboratory; 09= other.


You may be wondering, “How do I know what codes to use?” Some routinely used ICD-9 codes are 250.01 (Type 1), 250.00 (Type 2), and 648.8 (Gestational). ICD-9 codes must have documentation of diagnosis from physician.


Another option is CPT codes. Here are a few examples: G0108- individual diabetes education session (30 minutes), G0109- group (up to 20) diabetes education session (30 minutes). With CPT codes, Medicare covers up to 10 hours of education (9 hours group, 1 hour of individual) for initial education then up to 2 hours per year thereafter. Other insurances will have their own guidelines for coverage. If you have a dietitian (have them apply for a Medicare provider ID), they may be able to bill separately for Medical Nutrition Therapy (MNT) not included in the 10 hours of initial education.


If you want to find out about other billing codes you may check out the Pharmacist Services Technical Advisory Coalition website: www.pstac.org. You may try new MTM codes if you are conducting MTM that is not part of your diabetes education program. Here are some commonly used codes for MTM: 0115T (Initial encounter - 15 minutes), 0116T (Subsequent encounter), 0117T (Each additional 15 minutes). There are also Evaluation and Management (E & M) codes. Be aware of what “incident to billing” is but I would encourage you to bill at the level of service you believe you provided. The key to ensure reimbursement is to document as much as you can about what services you provided.


Here are some other billing codes that may be useful. Some common laboratory codes are (use QW modifier for CLIA waived): Full lipid panel- 80061 QW, Fasting plasma glucose- 82497 QW, HbA1c- 83036 QW, ImmunoDip- 83518 QW, Fingerstick- 36416 (not payable by Medicare). Brand new this year is the ability to bill for monofilament foot examinations. You definitely have to have this evaluation ability stated in your protocol, be very careful we do not diagnose! The code for monofilament foot examination is 2028F.


You may want to consider creating a carbon copy “superbill” (most physician's use this format) at time of service. With this patients can sign to prove they received services, patients can keep as a receipt of serviced rendered, and pharmacists can keep for billing. This will serve as your receipt and make keeping track of what occurred during visit easier.


Remember to bill for everything that you did! Even if you know you may not get paid, you just might! The average insurance claim is rejected 3 times before it is paid and insurances aren't used to pharmacist billing.


Instead of only keeping paper records consider electronic medical records. These help organize billing, SOAP notes, tracking appointments, tracking outcomes, and screening events. There are two companies located in Des Moines (in same building) can may help you with this aspect. One is Outcomes Pharmaceutical Healthcare: www.getoutc omes.com. The other is Protocol Driven Healthcare Inc.: www.pdhi.com. These companies can help you develop your protocol, bill insurance, manage paperwork, and create reasonable pricing. If you decide to use their services, please tell them where you got your “referral” from.


There are numerous other avenues related to diabetes services that pharmacists can participate in. These services can be incorporated into diabetes education program or can be completely independent of each other. I will not get into great detail about each different service, but some ideas are Insulin Pump Therapy Training and Follow-up, Continuous Glucose Monitoring System (CGMS), Spirometry monitoring with Exubera, Glucometer Training, and fitting patients with diabetic footwear.


A parting word of wisdom…”Even if you are on the right track, you will still get run over if you just sit there.” -Will Rogers please don't “just sit there”; make a difference in the lives of your patients with diabetes. Here are some helpful resources

    • American Association of Diabetes Educators
      • www.aadenet.org
    • National Certification Board of Diabetes Educators
      • www.ncbde.org
    • American Nurses Credentialing Center
    • National Institute for Standards in Pharmacist Credentialing

If you are feeling scholarly, here is a post-test regarding billing.

 

  • As a pharmacist you can only bill for diabetes education using pharmacist specific CPT codes (MTM codes). (True or False)
    • False- you can use MTM codes but reimbursement will most likely occur if recognized diabetes education CPT codes (G0108 or G0109) or more established E&M codes are used

  • The only way to bill for incident to diabetes education is if you are employed by a clinic and in same physical location as physician. (True or False)

    • True- do not bill under a physician's name unless you meet all criteria for incident to billing

  • It is not required for a physician to oversee a diabetes education program certified by IA Dept of Public Health. (True or False)

    • False- a physician must oversee and be on the advisory board, as does an RN, RPh, & RD.


  • What does S.W.O.T. stand for?

    • Strengths, Weaknesses, Opportunities & Threats involved with organization analysis


  • To provide lab services a pharmacy has to be CLIA certified. (True or False)

    • True- most pharmacies will only need to have a CLIA waiver certificate but higher complexity certifications can be obtained if desired.
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