ReimbursementNutr 564: Summer 2007

Objectives Identify the components of

reimbursement Describe the barriers Identify resources for MNT

reimbursement

Terms Medigap policy –

a privately purchased individual or group health insurance policy designed to supplement Medicare coverage

Medicare + ChoiceMedicare-covered benefits that are provided by

managed care plans, e.g., HMOs, PPOs, etc, instead of the traditional Medicare program. May offer additional benefits, e.g., prescription drug benefits

Terms Participating Provider

A physician or practitioner who signs a participation agreement/contract to accept assignment on all claims submitted to Medicare

Terms False Claim

Is a claim for payment for services or supplies that were not provided specifically as presented or for which the provider is otherwise not entitled to payment A service or a supply that was never provided A service for a diagnosis code other than the

true diagnosis code in order to obtain reimbursement for service which would otherwise not be eligible

A claim for a higher level of service A claim for a service that was provided by an

unlicensed/credentialed individual

Reimbursement Details about this topic

The Third Party System 1st party = the patient 2nd party = the provider 3rd party = the insurer

who manages the payment

Reimbursement Billing systems to connect the

service to the compensation Standards

• Who are qualified professionals to provide the service?

RD Credential

Continuing Education

Regulatory oversight - Dept of Licensing

Reimbursement Billing systems to connect the

service to the compensation Insurers recognize the standards

Example: CAM process

Reimbursement Billing systems to connect the service

to the compensation Documentation system - INPUT

Identifies the type of service provided

Nutrition Counseling

Identifies the scope of the intervention

Initial Assessment

Follow-up

Identifies the duration

15 min intervals

Reimbursement Outpatient Billing - Codes

Universal Bill 1992• UB-92 Form• Standardized bill used in most

facilities for services billed to third party payers

• Requires two types of code numbers to be included on the bill

– ICD codes– Revenue codes

Urbanski P: 2001

Reimbursement ICD codes

International Classification of Diseases

Diagnosis codes

ICD - 9 CM Codes HCFA (CMA) provides updates and

training Contains 5 numbers

• first 3 are general disease system• 4th and 5th specific details on disease

system, age, severity, etc.

Urbanski P: 2001

Reimbursement ICD codes

Example

250 codes for diabetes

Physician sets the diagnosis

Urbanski P: 2001

Reimbursement Billing systems to connect the

service to the compensation Documentation system -

AuthorizationDocumentation of nutrition risk

* Diagnosis

* Age

* Guidelines

Reimbursement

Nutrition SupportClient not able to take 50% of

estimated nutritional needs

Calorie Count or Nutrition Intake Assess

Physician confirmation

Updated to revised periodically

Reimbursement Billing systems to connect the

service to the compensation Documentation system - Submission

ICD codes

Reimbursement Resources

American Dietetic Association• Web site • Annual Meeting - workshops

Dietetic Practice Groups• Managers in Clinical Care

• Consultants in Dietetics

Dietetics List Serves• Note: Specific discussion of fee rates is

illegal. Equates to price fixing.

Networking with local practitioners

Reimbursement Medicaid is very specific for the

states. Cannot compare between states.

Reimbursement Barriers

Insurance Policies• Medicaid policies for coverage• Private insurers’ practices

– Should be the same as Medicare or Medicaid

Changing regulationsDetails of submitting a claim

• ICD codes

Lack of systematic feedback / QA

Reimbursement Professional Activities

Support MNT LegislationKeep informedCommunicate to your

representatives

Reimbursement Involve your clients

Ask about reimbursement experience

• Do they know if they got compensated?• What has worked?

Share this information with other clients

Warn clients if insurance may not cover a service

CMS: Center for Medicare & Medicaid MNT

Ruling issued 11/1/01 Regulation took effect 1/1/02

CMS issues a “National Converge Determination”

Frequency of treatment Duration of treatment Relationship of MNT to other services Reimbursement rates

CMS and Reimbursement Requires credential

RD as defined by CDR State licensure or certification

Must be licensed or certified in every state of practice

Must “Enroll” as a Medicare provider

Reimbursement CPT Codes

Common Procedural Coding system which defines actual procedure or service that the healthcare professional performed

Level I

Level II

Level II

Urbanski P: 2001

Reimbursement New CPT Codes for MNT

97802 = MNT; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes.

97803 = Re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes

97804 = group (2 or more individual(s)), each 30

minutes.

Urbanski P: 2001

Reimbursement Relative Values Units (RVU) per

15 minute increment Set at .46 RVUs per 15 min

segment for 97802 and 97803 Set at .18 RVUs per 30 min

segment for 97804

Reimbursement Provider Number

Each RD should have a provider number. Forms

From 1-3 forms to complete depending on:

• practice setting

• employment relationship The RD’s local carrier can assist in this

processSee

http://www.hcfa.gov/Medicare/enrollment/contacts

Urbanski P: 2001

CMS and ‘Opting Out’

Why

A client with an eligible service need

Medicare Provider Opt Out

CMS and ‘Opting Out’

Medicare providerPro May be required by employer Two-year opt-out period

Con Coverage at set reimbursement rate

which is very low Paperwork Legally required to follow Medicare

guidelines including update bulletins

CMS and ‘Opting Out’

Opt-out Better reimbursement