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/