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Reimbursement Essentials

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Presentation on theme: "Reimbursement Essentials"— Presentation transcript:

1 Reimbursement Essentials
Sarah Butler, MS, RD, LDN Director of Reimbursement, MDA Registered Dietitian, Boston University Sargent Choice Nutrition Center

2 Agenda Steps required to be eligible to bill for nutrition services
Private Insurance Government Insurance Resources

3 Before you begin this process
Must officially be an RD In the state of Massachusetts must have completed the licensure process Information about licensure can be found here.

4 Let’s take a look at the information available in the “Coding, Coverage & Compliance tab

5 Join the Reimbursement Community to be in the “know” regarding the ever changing reimbursement environment

6 A place to ask reimbursement questions
Network Share ideas Practice management tips related to reimbursement Exchanging best practices ideas to advance coverage Cannot discuss information about the fees you collect

7 Example of interaction within community

8 Let’s take a look at the billing resource guide for RDs

9 MNT Coverage Chart is a good resource

10 National Provider Identifier (NPI)
10-digit number – similar to a social security number Each time you credential with an insurance company they will attach your NPI to your name and specialty Your NPI will remain with you regardless of your job, location or name changes Adoption mandated by HIPAA to improve the efficiency and effectiveness of electronic transmission of health information Use NPI: Each time you call an insurance company to verify benefits Each time you file a claim Some medical record systems utilize NPI as part of signature

11 NPI logistics No fee to obtain a NPI number Registration tips
Assure you have plenty of time to complete process – cannot save Generally will receive NPI number within 10 days Apply for NPI here:

12 Credentialing with Insurance Companies
You want to start the credentialing process at least six months prior to seeing your first patient Which insurance companies should you credential with? Which companies are popular in your area? Ask other RDs in practice about their experience with insurance companies Work on only two insurance companies at a time Each has a different process and working on too many at once is overwhelming and can lead to mistakes Council for Affordable Quality Healthcare has been developed to facilitate credentialing and re-credentialing process

13 Council for Affordable Quality Healthcare (CAQH)
The CAQH Universal Credentialing Datasource:

14 How does CAQH Work? RD enters the data required for credentialing application into the CAQH secure on-line database RD faxes (or s scanned images) of necessary licenses, pages requiring signatures, liability insurance contracts etc. RD will contact insurance company who they are applying to become credentialed with and ask that they send your credentialing information to CAQH Insurance company registers this application with CAQH. CAQH distributes this information to insurance companies who either approve or deny the application

15 Why work with CAQH Saves a significant amount of time
Minimizes paperwork Health plans traditionally require providers to update credentialing information every two or three years CAQH makes it easy – once you are all set up you wouldn’t even realize the health plans are going through the re-credentialing process Keeps information current CAQH will ask you to re-attest your information on a regular basis Only need to change information that may have changed Update scanned images of licenses, liability insurance, etc Keeps health plan records and directories up to date No fee for this service

16 Other things to explore
Employer Identification Number (EIN) If in private practice  whether or not to remain sole proprietor under your SSN Professional Liability Insurance Completing the W9 form If approved by the insurance company how to know whether to approve the contract View billing guide for RDs found on the Academy’s page on “Coding, Coverage & Compliance”

17 Insurers and Nutrition Coverage
Within same insurance company and same type of plan the nutrition coverage can be completely different Insurance rates, plans etc are all negotiated between the insurance company and the employer who is providing insurance to their employees Result is lots of variation in diagnoses covered, # of sessions covered, co-pay amount that the patient is responsible for

18 Factors to consider Some policies reimburse RDs individual
Some policies require RD is performing nutrition services in a primary care physicians office Referrals may be needed Special requirements – mainly diagnosis codes Variations in patient benefits Copayments Deductible Limits on # of visits What is covered? See MNT Coverage Chart on the Academy website

19 Current Procedural Terminology (CPT) Codes
CPT codes are numbers assigned to every task and service a medical practitioner may provide to a patient Used by insurers to determine the amount of reimbursement that a practitioner will receive by an insurer Code set is maintained and copyrighted by the American Medical Association (AMA) and has been adopted by the Secretary of Health and Human Services as the standard for reporting physician and other services on standard transactions These are the typical billing codes accepted by most insurance companies including federal and state programs such as Medicare and in some cases Medicaid. Check with the payer to verify CPT codes to use on claims

20 CPT Codes 97802: Medical Nutrition Therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minute unit 97803: Re-assessment and intervention, individual, face-to-face with the patient, each 15 minute unit 97804: Group (2 or more individuals) each 30 minute unit Example  If you met with patient for 1 ½ hour initial consult use procedure code x 6 units NOTE: time spent preparing for visit or any pre- or post- visit activities are not considered billable hours and should not be reported on the claim

21 Healthcare Common Procedure Coding System (HCPCS)
HCPCS codes have been established by the Center for Medicare & Medicaid Services Primarily represent items and supplies and non-physician services that are not covered by the AMA CPT codes Medicare, Medicaid, and private health insurers may use HCPCS procedure and modifier codes Examples: S9465: Diabetic management program, per dietitian visit S9470: Nutritional counseling, per dietitian visit

22 International Classification of Diseases, Clinical Modification (ICD-9) or Diagnosis Codes
Classification used in assigning codes to diagnoses associated with inpatient, outpatient, and physician office utilization in the US Every health condition can be assigned to a unique category and given a code, up to six characters long When filing claims you need to check inusurance policy to determine if coverage is available for the condition (ICD code) for nutrition services  “If medical diagnosis is not available from physician RD should use best available information to determine diagnosis code. Use of diagnosis code on a claim does not constitute a medical diagnosis by an RD for legal purposes.” (1) Referral Systems in Ambulatory Care—Providing Access to the Nutrition Care Process, Kren K. et. al., Journal of the American Dietetic Association. August 2008 (Vol. 108, Issue 8, Pages ). Referral Systems in Ambulatory Care – Providing Access to the Nutrition Care Process – Academy of Nutrition & Dietetics

23 Examples of Common ICD-9-CM Codes
307.1 – Anorexia Nervosa – Bulimia Nervosa – Eating Disorder Unspecified 579.0 – Celiac Disease 278.0 – Obesity – Morbid Obesity 256.4 – Polycystic Ovarian Syndrome

24 ICD-9 Codes  ICD-10 Codes Effective October 1, 2014 the ICD-9 code sets will be replaced by ICD-10 code sets To stay up to date see:

25 Common Private Insurance Companies in Massachusetts
Blue Cross Blue Shield Harvard Pilgrim Tufts Health Aetna Fallon Community United Healthcare

26 Exploring Medicare & Medicaid
MNT Provider Newsletter is a fantastic resource

27 Medicare Federal health insurance program for people age 65 and older, people of any age with permanent kidney failure and certain disabled people under age 65. Managed by the Centers for Medicare & Medicaid Services, part of the Department of Health & Human Services Medicare Part A (Hospital Insurance) Medicare Part B (Medical Insurance) DSMT Recognized Program Information

28 Government Insurance Medicare/Medicaid Diabetes Chronic Kidney Disease

29 Obesity Effective November 29, 2011 Medicare covers screening and intensive behavioral counseling for obesity by primary care providers in primary care settings for Medicare beneficiaries with BMI ≥ 30. CMS does not preclude Primary Care Practitioners from referring eligible beneficiaries to other practitioners for counseling, however, coverage remains only in the primary care setting.

30 Cardiovascular Disease
Effective November 9, 2011 Medicare covers an annual visit for intensive behavioral counseling for cardiovascular disease to promote a healthy diet Limits this service to the primary care setting RDs should work collaboratively with primary care providers to provide counseling, however, the services would be billed under the physician

31 Annual Wellness Visit (AWV)
As a result of the Affordable Care Act, within 12 months of enrolling in Medicare Part B, new Medicare beneficiaries are eligible for a one time “Welcome to Medicare Visit” Annual wellness Visit can be billed annually provided 11 full months has passed since the last visit for these services from the physician/practice.

32 Who Can Provide AWV Service
The Centers for Medicare & Medicaid Services (CMS) allow the AWV to be provided by: physicians (MD or DO) physician assistants, nurse practitioners, clinical nurse specialists medical professionals (health educators, registered dietitians, or nutrition professionals, or other licensed practitioners) or a team of such medical professionals, working under direct supervision of a physician

33 Direct Supervision CMS defines “direct supervision” as follows:
“Direct supervision in the office setting means the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure.” The physician does not need to be in the room when services are provided. If an RD is going to provide all or part of the AWV, he or she must be present in the physician’s office during this visit.

34 Initial AWV – Required Components
Health risk assessment Medical/family history Measurement of height, weight, body mass index, blood pressure and other routine measurements as deemed appropriate A list of current providers and suppliers Screening for cognitive impairments Screening for depression Assessment of functional status Establishment of a written screening schedule Establishment of a list of risk factors and conditions for which treatment is being received or recommended Personal health advice and appropriate referrals for education or preventive services

35 Initial AWV – Billing and Coding
RDs cannot directly bill for the service; the service must be provided under "direct supervision" of the physician Billed using code G0438 Can be billed once in a beneficiary's lifetime No specific diagnosis codes are required, but one must be included on the claim. Medical providers should choose an ICD-9-CM diagnosis code or contact the local Medicare Administrative Contractor for appropriate guidance.

36 Subsequent AWV Required Components of the Subsequent AWV:
Subsequent AWV services include updates to the key elements of the Initial visit. Billing and Coding the Subsequent AWV: RDs cannot direct bill for the service; the service must be provided under "direct supervision" of the physician Billed using code G0439 Can be billed annually provided that 11 full months have passed since the last AWV (dates of service must occur on or after January 1, 2012) No specific diagnosis codes are required, but one must be included on the claim. Medical providers should choose an ICD-9-CM diagnosis code or contact the local Medicare Administrative Contractor for appropriate guidance.

37 Enrolling for Medicare
RD can apply to become a Medicare Part B provider by completing the necessary enrollment application forms CMS 855I Form Other Forms Health Care Providers that will bill Medicare carriers (CMS 855B): health care providers that have formed a practice together and will bill Medicare as a single provider Individual Reassignment of Benefits (CMS 855R) RD submit reassignment enrollment form if employed at a clinic or facility that will submit Medicare Part B claims forms and collect payment on behalf of the RD RDs who do not enroll in Medicare Part B will have to refer qualifying clients to RDs who are enrolled as Medicare providers

38 Medicare MNT Coverage Academy is actively lobbying to have Pre-Diabetes covered

39 Health Reform New Reimbursement Models New Coverage
“favor hospital and physician alignment, including physician employment, over the traditional private practice model.” Bundled payments, ACOs, PCMH Great incentives for PCMH Increased primary care reimbursement rate Hospitals may be looking to buy primary care practices Hospitals will be penalized for readmissions New Coverage Medicaid: ~40% increase from Health Insurance Exchanges: 24 million PwC “Health Reform: Prospering in a Post-Reform World.”

40 Reform Impact on RD? “Each sector will feel direct impacts from the new law and during the months following the signing of the legislation, many people may ask, “What does this mean to me?” – PwC report Decrease in fee for service Will the RD be more attractive? Will these be covered? Skype Based Visits Telephone Coaching Use of smart phones

41 Tracking Your Outcomes
Helps support public policy Helps with referrals Makes you feel good!

42 Academy Resources Coding, Coverage & Compliance Medicare MNT
Medicare MNT MNT Reimbursement Community of Interest Nutrition Entrepreneurs DPG Marsha Schofield, MS, RD, LDN Director, Nutrition Services Coverage ,  ext.  4787

43 Massachusetts Resources
Massachusetts Dietetic Association Legislation & Advocacy  Reimbursement Reimbursement Committee

44 Resources Centers for Medicare & Medicaid Services National Provider Identifier (NPI) CAQH Universal Provider Datasource Books Linda Arpino: Rise to Success Nutrition Practice Manual Ann Silver; Making Nutrition Your Business: Private Practice and Beyond

45 Thank You! Questions? If questions come up later…

46 References Referral Systems in Ambulatory Care—Providing Access to the Nutrition Care Process, Kren K. et. al., Journal of the American Dietetic Association. August 2008 (Vol. 108, Issue 8, Pages ). “Health Reform: Prospering in a Post-Reform World.” PricewaterhouseCoopers, Health Research Institute, May 2010. The Academy of Nutrition & Dietetics,

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