Patient Education on Diabetes – This was a really interesting question.
I thought it was a lot of fun when I read this because I could see the coder rolling
her eyes thinking, “What are you thinking?”
Q: We have a client with type-1 diabetes and I get 3 encounter forms a day for when this
nurse gives the client her insulin and every time she marks the box for administering insulin
(which is the proper thing to do) and also marks the 98960 box for patient education.
I am assuming this is like a home-health type visit and I did home health for a long time
and you have the RN’s notes and you have the nurse’s notes.
And like everything else, if it’s not written down, it’s not done.
Sounds like this nurse wanted to make sure get credit for everything she was doing.
I have a question: the nurses here at our facility do education/training self- management
with our clients, which are children and type-1 diabetes.
Again, especially for children and the parents, a lot of trainings involved in there.
She went on to say this nurse is pushing 98960 for every nurse visit note times 3 a day.
I don’t think we can bill 3 times a day every single day, this kid is in our care
for her education of diabetes.
Can we?
Our clients are her for 6-9 months.
That’s an awful lot of patient education on diabetes?
A: Let’s look at the code itself first.
98960 - Education and training for patient self-management by a qualified, nonphysician
health care professional using a standardized curriculum, face-to-face with the patient
(could include caregiver/family) each 30 minutes; individual patient – there are other codes
for additional patients.
A physician or other health care professional provides education and training to a patient
on how to manage a disease, injury, or other health problem – this is a guideline that
are right before the 98960 codes, so the manual they’ll have specific guidelines related
to following codes and then it will have more guidelines listed.
So that’s where I got this information.
It went on to say: Family members of the patient or other caregivers may also be present.
The instruction based on a standard curriculum, though it may be modified slightly as circumstances
dictate.
Definitely, they’re being very clear that you have to have a curriculum, a beginning
and end of goals you want your patient to have learned.
That’s what I think of the curriculum, not just, “Oh!
Today, we’re going to talk about disposing of your needles,” and “Oh!
Tomorrow, we’re going to talk about how to give injections and practice on oranges,”
and “Oh!
Today, let’s talk about how to pick up your insulin from the pharmacy.”
So, like that, it’s going to be standard.
The CPT manual is very clear on this.
The purpose of the education and training services is to teach the patient (may include
caregiver[s]) how to effectively self-manage the pt’s disease(s).
Education and training related to subsequent reinforcement or due to changes in the pt’s
condition or treatment plan are reported in the same manner as the original education
and training.
Again, this gives you a little leeway because they’re saying you’re going to train your
patient, and let’s say you got a young boy here.
He looks to be about eight, nine years old and they have very short attention spans.
But this is very critical, you don’t mess with diabetes, and he can get sick very quickly
if he doesn’t understand the concept of exercises versus the amount of eating he does
and the sleep, and so on and so forth.
And what constitutes exercise, because sometimes just playing out in the backyard maybe more
exercise than you think.
So, you educate the patient and then you got to educate the parents, then you got to educate
the grandparents, probably.
Again, this could be spread out especially if you’re doing home visits and the grandparents
aren’t there on a specific day.
And also, changes, let’s say the patient gets an ear infection and has to take an antibiotic.
Blood levels go up and down differently when you’re on antibiotics or even a steroid
they might put a child on to dry things up.
Again, more education will be needed for the parent especially.
The qualifications of the nonphysician healthcare professionals and the content of the educational
and training program must be consistent with guidelines or standards established or recognized
by a physician society, nonphysician healthcare professional society/association, or other
appropriate source.
It’s not really ambiguous because they’re telling you, you need to have a standard training
plan set in place for maybe adults, teenagers, children, caregivers, parents, grandparents,
school people - if the child is in public school.
This is where you can come in to some problems though.
This is what I was just thinking off the top of my head – so your nurse is using 98960
for every visit that she goes out, and she goes out 3 times a day to do injections and
is going to do that for six months.
Well, then, an auditor comes in and says each time you use 98960, you better document the
time you start, the time you stop the education.
Not the nurse’s visit, not the time the nurse’s visit with home health, it’s very
clear you’ve got to do the time in and the time out.
But this is separate; this is the education part of the visit.
So, if you got there at 10:00 in the [morning] and you started your education at 10:30 and
you ended the education at 10:45 and the visit was over at 10:50.
Then you’ve documented how much time in education was given during that visit.
Describe the education given so that it shows change from previous education given.
Be very specific and include copy of literature given – this is very important, I know the
nurses used to do this quite a bit with home health.
Let’s say the patient, especially physical therapy, they were training them – the physical
therapist would attach photocopies of the documentation that she gave the patient to
show them the exercises that they were to use while they’re recovering from a broken
hip after they just got home from that.
It was all on her note so that an auditor could come through and say, “Yes, I see
that you did all of this work.”
So I would think that you would need to have that if you’re giving education and its
specific curriculum.
If you don’t want to attach all of that, then you would have a separate notebook for
type-1 diabetic education for a child, type-1 education for the caregiver, and then say
“Refer to diabetic education book, page 1 section 2 was given on 8/15, 14.”
Then you could document it, that an auditor could come back and say, “OK.
I see you went out in the morning and you did this education for the mother.
You went out in the afternoon when you gave the shot, you educated the child.
When you went out in the third injection in the evening, the grandmother was there, and
so you gave education for them.
This is the documentation you gave them,” and then your plan would be: tomorrow when
you go out in the morning...
blah, blah, blah.
Be as specific as you can.
It will be very important to show that there is education given three times a day for thirty
minutes every day in a six month period of time.
Most of your patients, if it’s like home health, they are going to be there for six
months, they’ve gotten an approval for six months with the insurance, and the insurance
company itself is going to want to know what were you training all of this time three times
a day?
But if you have a set curriculum where you can say, “OK, I know I’m going out three
times a day times however many times that is in six months,” then you can say a standard
policy, it’s notebooks there or whatever education you’re doing, you’re being very
specific.
You caneven write down the questions that the patient had or the parent had, that would
mean why you would go to 30 minutes or beyond 30 minutes.
Really, in my mind, this is something that a compliance officer needs to establish in
an office, that’s where they come in and train the office staff, train the clinicians
and make sure that you have something like that notebook for education.
And I’m sure diabetes isn’t the only education that you’re doing for children.
It could be other, it could be a wound vac, it could be a child who’s in chemotherapy
and stuff, and the nurse has to come out and do special training during that time.
But you have notebook for all of those different things.
And then, if that is in fact what they do, you’re covered.
If they can’t do that or can’t document, then I would definitely say don’t be clicking
that code on your little sheet.
That was pretty interesting; I enjoyed looking at that one.