Presentation on theme: "Reimbursement Essentials"— Presentation transcript:
1 Reimbursement Essentials Sarah Butler, MS, RD, LDNDirector of Reimbursement, MDARegistered Dietitian, Boston University Sargent Choice Nutrition Center
2 Agenda Steps required to be eligible to bill for nutrition services Private InsuranceGovernment InsuranceResources
3 Before you begin this process Must officially be an RDIn the state of Massachusetts must have completed the licensure processInformation 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 NetworkShare ideasPractice management tips related to reimbursementExchanging best practices ideas to advance coverageCannot discuss information about the fees you collect
10 National Provider Identifier (NPI) 10-digit number – similar to a social security numberEach time you credential with an insurance company they will attach your NPI to your name and specialtyYour NPI will remain with you regardless of your job, location or name changesAdoption mandated by HIPAA to improve the efficiency and effectiveness of electronic transmission of health informationUse NPI:Each time you call an insurance company to verify benefitsEach time you file a claimSome 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 saveGenerally will receive NPI number within 10 daysApply for NPI here:https://nppes.cms.hhs.gov/
12 Credentialing with Insurance Companies You want to start the credentialing process at least six months prior to seeing your first patientWhich insurance companies should you credential with?Which companies are popular in your area?Ask other RDs in practice about their experience with insurance companiesWork on only two insurance companies at a timeEach has a different process and working on too many at once is overwhelming and can lead to mistakesCouncil 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: https://upd.caqh.org/oas
14 How does CAQH Work?RD enters the data required for credentialing application into the CAQH secure on-line databaseRD 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 CAQHInsurance 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 paperworkHealth plans traditionally require providers to update credentialing information every two or three yearsCAQH makes it easy – once you are all set up you wouldn’t even realize the health plans are going through the re-credentialing processKeeps information currentCAQH will ask you to re-attest your information on a regular basisOnly need to change information that may have changedUpdate scanned images of licenses, liability insurance, etcKeeps health plan records and directories up to dateNo 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 SSNProfessional Liability InsuranceCompleting the W9 formIf approved by the insurance company how to know whether to approve the contractView 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 differentInsurance rates, plans etc are all negotiated between the insurance company and the employer who is providing insurance to their employeesResult 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 officeReferrals may be neededSpecial requirements – mainly diagnosis codesVariations in patient benefitsCopaymentsDeductibleLimits on # of visitsWhat 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 patientUsed by insurers to determine the amount of reimbursement that a practitioner will receive by an insurerCode 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 transactionsThese 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 Codes97802: Medical Nutrition Therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minute unit97803: Re-assessment and intervention, individual, face-to-face with the patient, each 15 minute unit97804: Group (2 or more individuals) each 30 minute unitExample If you met with patient for 1 ½ hour initial consult use procedure code x 6 unitsNOTE: 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 ServicesPrimarily represent items and supplies and non-physician services that are not covered by the AMA CPT codesMedicare, Medicaid, and private health insurers may use HCPCS procedure and modifier codesExamples:S9465: Diabetic management program, per dietitian visitS9470: 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 USEvery health condition can be assigned to a unique category and given a code, up to six characters longWhen 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
24 ICD-9 Codes ICD-10 CodesEffective October 1, 2014 the ICD-9 code sets will be replaced by ICD-10 code setsTo stay up to date see:
25 Common Private Insurance Companies in Massachusetts Blue Cross Blue ShieldHarvard PilgrimTufts HealthAetnaFallon CommunityUnited Healthcare
26 Exploring Medicare & Medicaid MNT Provider Newsletter is a fantastic resource
27 MedicareFederal 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 ServicesMedicare Part A (Hospital Insurance)Medicare Part B (Medical Insurance)DSMT Recognized Program Information
28 Government InsuranceMedicare/MedicaidDiabetesChronic Kidney Disease
29 ObesityEffective 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 dietLimits this service to the primary care settingRDs 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 specialistsmedical 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 assessmentMedical/family historyMeasurement of height, weight, body mass index, blood pressure and other routine measurements as deemed appropriateA list of current providers and suppliersScreening for cognitive impairmentsScreening for depressionAssessment of functional statusEstablishment of a written screening scheduleEstablishment of a list of risk factors and conditions for which treatment is being received or recommendedPersonal 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 physicianBilled using code G0438Can be billed once in a beneficiary's lifetimeNo 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 physicianBilled using code G0439Can 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 formsCMS 855I FormOther FormsHealth 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 providerIndividual 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 RDRDs 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 CoverageAcademy 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, PCMHGreat incentives for PCMHIncreased primary care reimbursement rateHospitals may be looking to buy primary care practicesHospitals will be penalized for readmissionsNew CoverageMedicaid: ~40% increase fromHealth Insurance Exchanges: 24 millionPwC “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 reportDecrease in fee for serviceWill the RD be more attractive?Will these be covered?Skype Based VisitsTelephone CoachingUse of smart phones
41 Tracking Your Outcomes Helps support public policyHelps with referralsMakes you feel good!
42 Academy Resources Coding, Coverage & Compliance Medicare MNT Medicare MNTMNT Reimbursement Community of InterestNutrition Entrepreneurs DPGMarsha Schofield, MS, RD, LDNDirector, Nutrition Services Coverage, ext. 4787
44 Resources Centers for Medicare & Medicaid Services https://nppes.cms.hhs.gov/NPPESNational Provider Identifier (NPI)CAQH Universal Provider DatasourceBooksLinda Arpino: Rise to Success Nutrition Practice ManualAnn Silver; Making Nutrition Your Business: Private Practice and Beyond
45 Thank You! Questions? If questions come up later… Office:
46 ReferencesReferral 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, eatright.org