MAXIMIZING REIMBURSEMENT FOR OUTPATIENT MNT:

THE BREAKDOWN OF CODING & BILLING

By Jannick Davis

Morrison Dietetic Intern

January 2015

OVERVIEW OF CODING AND BILLING

1.) The importance of MNT2.) Designing an outpatient MNT focused program

Steps to making the program a success3.) The breakdown of Coding & Billing

National Provider Identifier & what it is used for ICD codes Area of Medicare that is reimbursable to

R.D’sDiagnoses covered by Medicare &

coverage criteriaBreakdown of billing

PQRS system

4.) References5.) Reference Links

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

WHY IS MNT IMPORTANT?

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.

Outpatient programs

are the Key to making an impact

In the surrounding community

Continued education for patients Post Discharge

DESIGNING A VIABLE OUTPATIENT PROGRAM: 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

Understanding which diagnoses are covered by medicare/medicaid Help determine

reimbursement for service to estimate revenue/expenses

Go to: www.cms.gov/apps/physician-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

STEP 4 : MAKE CASE MANAGEMENT & FINANCE PART OF THE OUTPATIENT

TEAM

Determine charges/estimate actual reimbursement

Track cost of providing services

Measure profit & Loss

STEP 5: BILLING & CODING

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)

STEP 6 & 76. 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 reimbursementReference Link:

www.ihs.gov/MedicalPrograms/Diabetes/HomeDocs/Resources/InstantDownloads/MNT_Reimb_Guide_Adden_508c.pdf

WHAT 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• IF YOU HAVE YOUR OWN PRACTICE YOU

WILL NEED IT TO MAKE CLAIM TRANSACTIONS.

https://nppes.cms.hhs.gov/NPPES/ (apply for NPI)

NEXT ICD Codes

MEDICAL DISEASE CONDITION CODE DETERMINED BY THE PATIENTS REFERRING PHYSICIAN OR TRAINED BILLER

LOOKING 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 Medicare1)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 diabetes2)Kidney Disease Non-dialysis kidney disease (GFR 13-50)Kidney transplant within the last 6 months

COVERED SERVICES CONTINUED

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/m2

STEP 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

SERVICES INCLUDED FOR REIMBURSABLE MNT CPT CODES ARE……

Code #

Service Billable increments in minutes

97802 -Initial Assessment/Intervention-Face to Face

15 minutes = 1 billable unite

97803 MNTReassessment/interventionIndividual (Face to Face)

15 minutes = 1 billable unit

97804 MNTGroup (2 or more individuals)

30 minutes = 1 billable unit

G0270 MNT reassessment (2nd referral) for change in condition/diagnosisIndividual

15 min

G0271 MNT reassessment (2nd referral) for change in diagnosis/treatmentGroup

30 min

EXAMPLE PROBLEM FOR REIMBURSABLE UNITS

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

COVERED DIAGNOSIS AND TOTAL BILLABLE HOURS FOR MEDICARE

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

SERVICES 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

IMPORTANT FORMS FOR REIMBURSEMENT

For Professional Billing RD completes:

855I form855R formFacility bills Medicare using

form CMS 1500

Facility BillingRD doesn’t complete any

formsFacility bills Medicare using

form CMS 1450 (UB-04)

WHAT DOES PQRS STAND FOR??

Physician Quality Reporting SystemIs a way for a facility to get a bonus by

• Reporting measures on at least 50% of claims provided by the practitionerReport 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.

IN 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.

REFERENCES

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

REFERENCE LINKS

www.eatright.org/HealthProfessionals/content.aspx?id=6864&terms=iom%20nutrition%20therapy

www.ihs.gov/MedicalPrograms/Diabetes/HomeDocs/Resources/InstantDownloads/MNT_Reimb_Guide_Adden_508c.pdf

www.cms.gov/apps/physician-fee-schedule/license-agreement.aspx

https://nppes.cms.hhs.gov/NPPES/