1. M AXIMIZING R EIMBURSEMENT FOR O UTPATIENT MNT: T HE BREAKDOWN OF CODING & B ILLING By Jannick Davis Morrison Dietetic Intern January 2015

2. O VERVIEW OF C ODING AND B ILLING 1.) The importance of MNT 2.) Designing an outpatient MNT focused program  Steps to making the program a success 3.) The breakdown of Coding & Billing  National Provider Identifier & what it is used for  ICD codes  Area of Medicare that is reimbursable to R.D’s  Diagnoses covered by Medicare & coverage criteria  Breakdown of billing  PQRS system 4.) References 5.) Reference Links

3. CDC reports “research has shown that good nutrition can help lower the risk of many chronic diseases including heart disease, stroke, some cancers, diabetes, and osteoporosis.” 1

4. W HY IS MNT I MPORTANT ? Two Key words Prevention AND Wellness in the community As R.D’s it is part of our training and expertise to strategically provide healthful information to our patients who have pre-disease and chronic disease states……in a way that they will be able to make lifestyle changes in an effective manner. Bottom Line: MNT can improve their overall health and well-being and minimizing hospital visits and need for prescription medications.

5. Outpatient programs are the Key to making an impact In the surrounding community Continued education for patients Post Discharge

6. D ESIGNING A V IABLE O UTPATIENT P ROGRAM : 7 STEP GUIDE Step 1 Determine the opportunities or demand in your organization or community  Areas where RD’s can make an impact:  Diabetes and Renal Disease (reimbursable for MNT through Medicare)  Patients who are seen at Cancer Centers can benefit from MNT due to variable nutrition risks  Chronic conditions such as Congestive Heart Disease and Obesity can benefit greatly in lifestyle changes

7. Understanding which diagnoses are covered by medicare/medicaid Help determine reimbursement for service to estimate revenue/expenses Go to: www.cms.gov/apps/physici an-fee-schedule/license- agreement.aspx www.cms.gov/apps/physici an-fee-schedule/license- agreement.aspx Form a Team with Registration/Scheduling Provide forms to patients for coverage, waivers for when services are not covered Step 2 Step 3

8. S TEP 4 : M AKE C ASE M ANAGEMENT & F INANCE PART OF THE OUTPATIENT TEAM Determine charges/estimate actual reimbursement Track cost of providing services Measure profit & Loss

9. S TEP 5: B ILLING & C ODING Establish a charge master in coordination with finance, listing procedure codes known as CPT’s(Current Procedural Terminology). 3 Used in MNT for types of encounters (These will be discussed later in the powerpoint)

10. S TEP 6 & 7 6. Documentation  Policies should be put in place for  Billing  Documentation templates that meet regulatory requirements for patient encounters 7. Tracking Charges/Hours and Costs  Procedures for tracking volume & charges  Track charges against labor and other costs  Having experienced personable staff to provide MNT  Precise and complete documentation of services is key in obtaining reimbursement Reference Link: www.ihs.gov/MedicalPrograms/Diabetes/Ho meDocs/Resources/InstantDownloads/MNT _Reimb_Guide_Adden_508c.pdf www.ihs.gov/MedicalPrograms/Diabetes/Ho meDocs/Resources/InstantDownloads/MNT _Reimb_Guide_Adden_508c.pdf Reference Link: www.ihs.gov/MedicalPrograms/Diabetes/Ho meDocs/Resources/InstantDownloads/MNT _Reimb_Guide_Adden_508c.pdf www.ihs.gov/MedicalPrograms/Diabetes/Ho meDocs/Resources/InstantDownloads/MNT _Reimb_Guide_Adden_508c.pdf

11. W HAT DO YOU NEED TO KNOW ABOUT CODING BILLING ?? Lets start from the beginning!! An NPI (National Provider Identifier is needed in order to make claim transactions. (Unique ID #) As an RD: IF YOU WORK WITH A PRACTICE YOU WILL NOT NEED YOUR OWN NPI I F YOU HAVE YOUR OWN PRACTICE YOU WILL NEED IT TO MAKE CLAIM TRANSACTIONS. https://nppes.cms.hhs.gov/NPPES/ (apply for NPI) https://nppes.cms.hhs.gov/NPPES/ NEXT    ICD Codes M EDICAL DISEASE CONDITION CODE DETERMINED BY THE PATIENTS REFERRING PHYSICIAN OR TRAINED BILLER

12. L OOKING AT THE STEPS IN MORE DETAIL : Step 2: Understanding covered services PART B is the area that allows RD’s to be reimbursed for MNT by Medicare Covered Diagnosis by Medicare 1)Diabetes: Type 1 & 2  Fasting Blood Glucose ≥ 126 mg/dl on two different occurrences  2 hour post glucose challenge ≥ 200 mg/dl on 2 different occurrences  Random glucose test over 200 mg/dl with symptoms of uncontrolled diabetes 2)Kidney Disease  Non-dialysis kidney disease (GFR 13-50)  Kidney transplant within the last 6 months

13. C OVERED S ERVICES C ONTINUED RD’s can also provide MNT for Intensive Behavioral Therapy for Obesity Under supervision of physician Billed under Incident to Physician Services by Medical Group not by RD Medicare requires patient must meet specific criteria BMI ≥ 30 kg/m 2

14. S TEP 5 IN CLOSER DETAIL : CPT (Current Procedural Terminology) are known as the ‘WORK’ value Meaning…… the amount of time and effort put in to pre- intra- and post service Payment amount for codes determined by:  Medicare  Medicaid  & private Health care Insurances RD’s are paid @ 85 % of what a Physician is for providing service by Medicare

15. S ERVICES INCLUDED FOR R EIMBURSABLE MNT CPT CODES ARE …… Code #ServiceBillable increments in minutes 97802-Initial Assessment/Intervention -Face to Face 15 minutes = 1 billable unite 97803MNT Reassessment/intervention Individual (Face to Face) 15 minutes = 1 billable unit 97804MNT Group (2 or more individuals) 30 minutes = 1 billable unit G0270MNT reassessment (2 nd referral) for change in condition/diagnosis Individual 15 min G0271MNT reassessment (2 nd referral) for change in diagnosis/treatment Group 30 min

16. E XAMPLE P ROBLEM FOR REIMBURSABLE U NITS RD spent 53 minutes in face-to-face time with an individual patient. The units she will charge are? ANSWER: 3 UNITS 53 MINUTES/15 MIN/UNIT RD will basically be reimbursed for 45 minutes of her time spent with patient RD spent 70 minutes with a group of 3 patients. The units she will charge are? Answer: 2 UNITS 70 minutes/30 min/unit

17. C OVERED D IAGNOSIS AND T OTAL B ILLABLE HOURS FOR M EDICARE Covered Diagnosis: Diabetes, Kidney Disease Billable Hours: 3 hours (15 minute units or 12 units first year) 2 hours subsequent years (8-15 minute units) Important Note: MNT and Diabetes Self Management are not covered on same day

18. S ERVICES INCLUDED FOR REIMBURSEMENT BY NON - PHYSICIAN QUALIFIED HEALTHCARE PROFESSIONAL 98960-98962: Education and training for patient self management (face to face) 98966-98968: Telephone assessment 98969: Online assessment and management service 99071: Educational supplies provided by physician for patient education at cost of physician 99366 & 99368: Medical team conference with or without patient/family

19. I MPORTANT FORMS FOR REIMBURSEMENT For Professional Billing  RD completes:  855I form  855R form  Facility bills Medicare using form CMS 1500  Facility Billing  RD doesn’t complete any forms  Facility bills Medicare using form CMS 1450 (UB-04)

20. WHAT DOES PQRS STAND FOR ?? Physician Quality Reporting System Is a way for a facility to get a bonus by Reporting measures on at least 50% of claims provided by the practitioner Report 3 measures 1)DM: HA1C Poor Control 2)DM: LDLP Control 3)DM high Blood pressure control 4)Adult kidney dz: BP management OR Report 1-2 measures for @ least 50 % of the time.

21. I N CLOSING …… It is key to understand how coding and billing works in order to continue to provide places for nutrition services and support for the community and post hospital patients.

22. R EFERENCES 1. Ravasco P, Monteiro-Grillo I, Vidal PM, Camilo ME, Dietary counseling improves patient outcomes: a prospective, randomized, controlled trial in colorectal cancer patients undergoing radiotherapy, Journal of clinical Oncology, 2005, 23(7): 1431-1438. Alphabet Soup: Understanding the Use of Coding/Biling Terminology Webinar Data Sheet Morrison Outpatient Toolkit: Steps to Reimbursement

23. R EFERENCE L INKS www.eatright.org/HealthProfessionals/content.as px?id=6864&terms=iom%20nutrition%20therapy www.ihs.gov/MedicalPrograms/Diabetes/HomeDo cs/Resources/InstantDownloads/MNT_Reimb_Gui de_Adden_508c.pdf www.cms.gov/apps/physician-fee- schedule/license-agreement.aspx https://nppes.cms.hhs.gov/NPPES/