Billing Codes & Reimbursement for Diabetes Technology Services

Description

Who Can Bill/ Other Notes

Increments/Frequency/Limits
For information on Fee Schedule, visit Physician Fee Schedule Search

G0108

Diabetes outpatient self- management training services, individual.

ADCES Accredited or ADA Recognized ONLY and varies by provider type.

Per 30 minutes (do not round up).

G0109

Diabetes outpatient self- management training services, group session (2 or more).

ADCES Accredited or ADA Recognized ONLY and varies by provider type.

Per 30 minutes (do not round up); FQHC’s and RHC’s excluded.

G0108 or G0109 with POS 02 modifier for Medicare; 95 modifier is often used for private payers but may vary.

By reporting place of service (POS) 02 modifier with HCPCS code G0108 (Diabetes outpatient self-management training services, individual, per 30 minutes) or G0109 (Diabetes outpatient self- management training services, group session (2 or more), per 30 minutes), the distant site practitioner attests that the beneficiary has received or will receive 1 hour of in-person DSMT services for purposes of injection training when it is indicated during the year.

ADCES Accredited or ADA Recognized ONLY and billed under program NPI#. (same as in person visits)

Per 30 minutes (do not round up). Medicare telehealth services, including individual and group DSMT services furnished as a telehealth service, could only be furnished by a physician, PA, NP, CNS, CNM, clinical psychologist, clinical social worker, or registered dietitian or nutrition professional, as applicable. RNs, Pharmacists, and other instructors are excluded.

DSMT via Telehealth extended after the PHE

Providers bill the same G-codes when providing DSMT via telehealth. Must still have accredited program to bill via telehealth.

Under the PHE: RNs and Pharmacists can provide DSMT via telehealth Audio only is allowed if visual mode is not available. Both hospital-based and office -based programs can provide DSMT via telehealth after the end of the PHE. 12/23 patient may be located at home.

Medicare DSMT payment rates are the same if service provided via telehealth or in-person

97802

MNT; initial assessment and intervention, individual, face-to-face with the patient. Can only be used once a year on a new patient. May be billed when telehealth.

RD/RDN ONLY

Each 15 minutes.

97803

MNT; re-assessment and intervention, individual, face-to- face with the patient. May be billed when telehealth.

RD/RDN ONLY

Each 15 minutes.

97804

MNT; group (2 or more individual(s)). May be billed when telehealth.

RD/RDN ONLY

Each 30 minutes.

G0270

Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease), individual, face to face with the patient. May be billed when telehealth.

RD/RDN ONLY

Each 15 minutes.

G0271

Medical nutrition therapy, reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition, or treatment regimen (including additional hours needed for renal disease), group (2 or more individuals). May be billed when telehealth.

RD/RDN ONLY

Each 30 minutes.

99091

Collection and interpretation of physiologic data (e.g., ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by education, training, licensure/regulation (when applicable). Requires one instance of communication which can be a call, video, or email.

Physician or QHP

Requiring a minimum of 30 minutes of time.

95249

Ambulatory CGM of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; patient provided equipment, sensor placement, hook-up, calibration of monitor, patient training, and printout of recording.

For Medicare - An MA, RN, LPN, or CDCES may perform the elements in CPT codes 95249 / 95250 if “incident to guidelines” are met, meaning they are providing the service directed by a physician or other qualified health care provider. Billed by physician or QHP.

Sensor for a minimum of 72 hours; printout of recording; may not be reported more than once for the duration that the patient owns the data receiver. Obtaining a new sensor and/or transmitter without a change in the receiver does not warrant reporting 95249 subsequent times.

95250

Ambulatory CGM of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; physician or other qualified health care professional (office) provided equipment, sensor placement, hook-up, calibration of monitor, patient training, removal of sensor and printout of recording.

For Medicare - An MA, RN, LPN, or CDCES may perform the elements in CPT codes 95249 / 95250 if “incident to guidelines” are met, meaning they are providing the service directed by a physician or other qualified health care provider. Billed by physician or QHP.

Sensor for a minimum of 72 hours, once per month or as directed by payer.

95251

Ambulatory CGM of interstitial tissue fluid via a personal wear subcutaneous sensor for a minimum of 72 hours; analysis, interpretation, and report. Can be attached to a telehealth visit.

MD, DO, NP, PA.

Once per month or as covered by payer.

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); individual patient.

Varies by payer – verify coverage directly with payer

Each 30 minutes.

98961

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); 2-4 patients.

Varies by payer – verify coverage directly with payer

Each 30 minutes.

98962

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); 5-8 patients.

Varies by payer – verify coverage directly with payer

Each 30 minutes.

99211

Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services.

Physicians can report 99211, but it is intended to report services rendered by other individuals in the practice, such as a nurse or other staff member. Unlike other office visit E/M codes, a 99211-office visit does not have any specific key- component documentation requirements.

5 minutes.

G0466

Federally qualified health center (FQHC) visit, new patient; a medically necessary, face-to-face encounter (one-on-one) between a new patient and a FQHC practitioner during which time one or more FQHC services are rendered and includes a typical bundle of Medicare-covered services that would be furnished per diem to a patient receiving a FQHC visit.

FQHC

One or more FQHC services are rendered and includes a typical bundle of Medicare- covered services that would be furnished per diem. Paid under the FQHC assigned encounter rate.

G0467

Federally qualified health center (FQHC) visit, established patient; a medically-necessary, face-to-face encounter (one-on-one) between an established patient and a FQHC practitioner during which time one or more FQHC services are rendered and includes a typical bundle of Medicare-covered services that would be furnished per diem to a patient receiving an FQHC visit.

FQHC

One or more FQHC services are rendered and includes a typical bundle of Medicare- covered services that would be furnished per diem.  Paid under the FQHC assigned encounter rate.

99490

Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements: Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient.
Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.
Comprehensive care plan established, implemented, revised, or monitored.

The CCM codes describing clinical staff activities (CPT 99487, 99489, and 99490) are assigned general supervision under the Medicare PFS. General supervision means when the service is not personally performed by the billing practitioner, it is performed under his or her overall direction and control although his or her physical presence is not required. Can be done via telehealth

At least 20 minutes; once per month.

99491

Chronic care management services, provided personally by a physician or other qualified health care professional, at least 30 minutes of physician or other qualified health care professional time, per calendar month, with the following required elements:
Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient.
Chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline.
Comprehensive care plan established, implemented, revised, or monitored.

Physicians and the following non- physician practitioners may bill CCM services: Clinical Nurse Specialists, Nurse Practitioners, PAs

At least 30 minutes, once per month.

99487

Complex chronic care management services, with the following required elements:  Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient. Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.
Establishment or substantial revision of a comprehensive care plan.
Moderate or high complexity medical decision making.
60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.

The CCM codes describing clinical staff activities (CPT 99487, 99489, and 99490) are assigned general supervision under the Medicare PFS. General supervision means when the service is not personally performed by the billing practitioner, it is performed under his or her overall direction and control although his or her physical presence is not required.

60 minutes, once per month.

99489

Each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure).
Complex CCM services of less than 60 minutes in duration, in a calendar month, are not reported separately. Report 99489 in conjunction with 99487. Do not report 99489 for care management services of less than 30 minutes additional to the first 60 minutes of complex CCM services during a calendar month.

Time spent directly by the billing practitioner or clinical staff counts toward the threshold clinical staff time required to be spent during a given month. CCM services that are not provided personally by the billing practitioner are provided by clinical staff under the direction of the billing practitioner on an “incident to” basis (as an integral part of services provided by the billing practitioner), subject to applicable state law, licensure, and scope of practice. The clinical staff are either employees or working under contract to the billing practitioner whom Medicare directly pays for CCM.

Additional 30 minutes, once per month; Complex CCM services of less than 60 minutes in duration, in a calendar month, are not reported separately. Report 99489 in conjunction with 99487. Do not report 99489 for care management services of less than 30 minutes additional to the first 60 minutes of complex CCM services during a calendar month.

99453

Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment

Physician or QHP

99454

Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days for collection of patient generated health data.

Physician QHP

Must have at least 16 days of data in the 30-day time period.

99457

Remote physiologic monitoring treatment management services requiring interactive communication with the patient/caregiver during the month.

Clinical staff, physician, other qualified health care professional time

20 minutes or more of clinical staff/physician/other qualified health care professional time in a calendar month.

99458

Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; additional 20 minutes

Clinical staff, physician, other qualified health care professional time

Add on code to 99457

99605

Medication therapy management service(s) provided by a pharmacist, individual, face-to-face with patient, initial 15 minutes, with assessment, and intervention if provided.

Pharmacist

Initial 15 minutes, new patient.

99606

Medication therapy management service(s) provided by a pharmacist, individual, face-to-face with patient, initial 15 minutes, established patient.

Pharmacist

Initial 15 minutes, established patient.

99607

Medication therapy management services provided by a pharmacist, individual, face-to-face with patient, each additional 15 minutes. (List separately in addition to code for the primary service).

Pharmacist

Each additional 15 minutes (Use 99607 in conjunction with 99605, 99606). National Average: N/A

98966

Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion.

RD/RDN

During the PHE, non-physician practitioners who are eligible to bill Medicare directly, including registered dietitians and nutritional professionals, may bill for audio-only telephone assessment and management services.* This list does not include RNs or pharmacists. Physicians, nurse practitioners, and physician assistants should use CPT® codes 99441—99443. These codes should not be used for DSMT.
This payment is ongoing in 2024.

98967

Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment: 11-20 minutes of medical discussion

RD/RDN

During the PHE, non-physician practitioners who are eligible to bill Medicare directly, including registered dietitians and nutritional professionals, may bill for audio-only telephone assessment and management services.* This list does not include RNs or management services.* This list does not include RNs or pharmacists. Physicians, nurse practitioners, and physician assistants should use CPT® codes 99441—99443. These codes should not be used for DSMT.
This payment is ongoing in 2024.

98968

Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion

RD/RDN

During the PHE, non-physician practitioners who are eligible to bill Medicare directly, including registered dietitians and nutritional professionals, may bill for audio-only telephone assessment and management services.* This list does not include RNs or pharmacists. Physicians, nurse practitioners, and physician assistants should use CPT® codes 99441—99443. These codes should not be used for DSMT.
This payment is ongoing in 2024.

98970

Qualified non-physician health care professional online digital evaluation and management, for an established patient, for up to seven days, cumulative 5-10 minutes during the 7 days;  minutes

RD/RDN, physical therapists, occupational therapists, speech language pathologists and clinical psychologists

These codes are designated for e-visits, specifically online assessment and management of a patient. These are not specifically designated for phone visits. The Medicare fact sheet states that RDNs, physical therapists, occupational therapists, speech language pathologists and clinical psychologists can provide the following e-visits and bill the following codes (RNs and pharmacists are not listed).

98971

Qualified non-physician health care professional online digital evaluation and management, for an established patient, for up to seven days, cumulative during the 7 days; 11-21 minutes

RD/RDN, physical therapists, occupational therapists, speech language pathologists and clinical psychologists

These codes are designated for e-visits, specifically online assessment and management of a patient. These are not specifically designated for phone visits. The Medicare fact sheet states that RDNs, physical therapists, occupational therapists, speech language pathologists and clinical psychologists can provide the following e-visits and bill the following codes (RNs and pharmacists are not listed).

98972

Qualified non-physician health care professional online digital evaluation and management, for an established patient, for up to seven days, cumulative during the 7 days; 21 or more minutes

RD/RDN, physical therapists, occupational therapists, speech language pathologists and clinical psychologists

These codes are designated for e-visits, specifically online assessment and management of a patient. These are not specifically designated for phone visits. The Medicare fact sheet states that RDNs, physical therapists, occupational therapists, speech language pathologists and clinical psychologists can provide the following e-visits and bill the following codes (RNs and pharmacists are not listed).

G2061 2063

Qualified non-physician health care professional online digital evaluation and management service, for an established patient, for up to seven days, cumulative during the 7 days; 5–10 minutes

Discontinued