January 29, 2013

I was recently asked the following question - which I want to highlight not because of the actual question but because it reflects a frequent state of practice - where a practitioner may bill for a certain service.  This question is also associated with being entirely unaware that your practice is engaged in a billable service, at all.    The solution - attend or have staff attend regular training, and/or make it a habit to work with a coding expert on not less than an annual basis to ensure you are coding and documenting properly, and maximizing your reimbursement through proper coding and documentation. 


Hi Jennifer,

Medicare now pays for DSMT (diabetes self management training), 30 minutes at a time, 10 hours in the first year. I have a diabetes educator in my practice that I do not pay, she is paid by one of the pharmaceutical companies, however, she is in my office and I do consult with the patient for a few minutes afterwards.  Sometimes there is a change in meds, sometimes not. Can I bill Medicare under these circumstances?

Dr. K


As this question is beyond my areas of expertise, I have asked Jackie Thelian of Medco Consultants to opine, and Jackie has provided the following: 

Yes, Medicare does reimburse for DSMT services. In the scenario described below the physician may not bill for the services of the Diabetic Educator. Firstly it does not appear the Diabetic Educator is an employee of the physician, second it does not appear she is linked to the doctor’s group and thirdly there is no indication the educator has a Medicare number.

If the physician is looking to get reimbursed  for his/her service he/she would document the service he/she is providing, which is indicated as speaking to the patient after the patient was seen by the educator and managing the patient’s prescriptions. If the documentation is sufficient enough support and E/M service and is medically necessary, the physician would bill this at the appropriate level of E/M service based upon his/her documentation.  Medicare does not pay for consults. Additionally this scenario does not meet the criteria of a consultation.

For additional information on a coding issue, Jackie may be reached at (718) 217-3802 or at JacquelineT@medcoconsultants.com.

Jackie Thelian CPC, CPC-I is a Healthcare Consultant, Certified Professional Coder, Author and sought after educator with over 20 years experience in business management and medical coding. She has been involved in physician practice management, billing and reimbursement issues and has taught extensively in academic medical centers, hospitals and private physician practices. For more information, call Medco Consultants at (718) 217-3802. 

An additional element of this question to address is whether the diabetes educator has an appropriate arrangement with the practice.  Is she subleasing space, licensing space, equipment and personnel?  The relationship must be defined so that it is clear there is no remuneration passing from either side in consideration for referrals.  Questions on this - email in or call me.