Review of Codes, Coverage Trends and Advocacy Resources

Pam Michael, MBA, RDDirector, American Dietetic

Association Nutrition Services Coverage Team

Session Objectives

• Recognize type of codes used for billing RD services

• Learn models of payment for health care professionals

• Identify groups to target for local coverage advocacy activities

• Recognize ADA coding and coverage resources

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Billing Nutrition Services..Getting started

NPI = National Provider Identifier

A standard unique identifier that replaces other provider numbers used on healthcare claims.

Purpose-- to improve the efficiency and effectiveness of the electronic transmission of health information.

A provider’s NPI will not change and will remain with the provider regardless of job or location changes.

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Type of Codes

Diagnosis codes (ICD-9-CM)

ICD-9- CM= International Classification of Diseases, Clinical Modification

A set of codes that describe an individual's disease or medical condition

Physicians and trained billers determine these codes

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 1375-1379).

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Examples of ICD-9 Diagnosis Codes

Chronic Kidney Disease (CKD) - 585.Xmust include a 4th digit

• 585.4; chronic kidney disease, Stage IV (severe)[Kidney damage with severe decrease in GFR (15-29)]

 Diabetes Mellitus – 250.XXmust include a 4th digit which indicates the type of complication, and must include a 5th digit which indicates the diabetes type and control• 250.00—type II or unspecified type, not stated as uncontrolled, without complication • 250.01—type I, not stated as uncontrolled, without complication• 250.02—type II or unspecified type, uncontrolled, without complication• 250.03—type I, uncontrolled, without complication

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Coming in 2013: ICD-10CM

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Transition to ICD-10-CM will impact all billing software, forms, and billing

procedures. All groups must convert to ICD-10-CM system by October 1, 2013. 

ICD-10-CM• Codes alpha-numeric, up to seven characters. - Digit 1 is alpha; digits 2 and 3 are numeric; digits 4 - 7 are alpha or numeric For example: E11.8 diabetes, type 2... with complication N18.3 chronic kidney disease, stage III

• Includes about 8,000 categories (IDC-9 included 4,000 categories.)

Type of Codes

CPT codes = Current Procedural Terminology codes (procedure codes) that describe the service performed by the healthcare professional

HCPCS codes = Healthcare Common Procedure Coding System developed by payers to describe services where no CPT code exists

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AMA CPT Process

Current Procedural Terminology (CPT) process:

• Code creation and valuation for payment- CMS

• Standardized Uniform Language- Medical, surgical procedures/services

• Communications Vehicle- Payers-- language of reimbursement- National/International research standardization

Used for research, quality assurance and reimbursement

• Pay for Performance– Guidelines provisions– Outcomes assessment

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MNT CPT Codes

97802 • MNT initial assessment and intervention,

individual, face-to-face, each 15 minutes97803

• MNT, reassessment and intervention, individual, individual, face-to-face, each 15 minutes

97804• MNT, group, 2 or more individuals, each 30

minutes

CPT codes, descriptions and material only are copyright ©2009 American MedicalAssociation. All Rights Reserved.

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HCPCS MNT “G” Codes

G0270 • MNT re-assessment and subsequent

intervention(s) following 2nd referral in the same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease), individual, face-to-face, each 15 minutes

G0271• MNT re-assessment and subsequent

intervention(s)…, group (2 or more individuals), each 30 minutes

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HCPCS DSMT “G” Codes

G0108 Diabetes outpatient self-management training

services, individual, per 30 minutes

G0109 Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes

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New Procedure Codes Applicable to RDs(however not for use with Medicare)

Education and Training Codes (98960-2): Not Medicare

Medical Team Conference (99366 and 99368):Not Medicare

Telephone Services (98966-68): non-face-to-faceservices; Not Medicare

On-line Medical Evaluation (98969): On-line assessment and management service…; not originating from a related assessment and management service

within the last 7 days; Internet or similar electronic communications. Not Medicare

CPT codes, descriptions and material only are copyright ©2009 American MedicalAssociation. All Rights Reserved.

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Payment models for nutrition services

Medicare Part A (hospital inpatient services)

• RD services, food and nutrition care bundled into hospital room and board payment. • RDs cannot separately bill (§482.28 Condition of Participation:

Food and Dietetic Services)http://www.cms.hhs.gov/manuals/downloads/som107ap_a_hospitals.pdf

Part B (outpatient services- fee for service) • RD MNT services paid from the Medicare Physician Fee Schedule. RDs get paid 85% of what a physician would be paid for MNT services.• RDs are able to independently bill for MNT services.

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Payment models for nutrition services

Medicare

End Stage Renal Disease (ESRD) facilities • Based on a prospective payment system known as the basic case-mix adjusted composite payment system.  The base composite rate includes RD services. • The facility is paid for services provided at the ESRD clinic for (RDs do not receive separate payment)

CMS Web page: http://www.cms.hhs.gov/ESRDPayment/

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Value Based Payment SystemsMedicare Physician Quality Reporting Initiative (PQRI)

• Adopted by Medicare Part B for certain providers, including RDs

• Provides incentive payments, 2.0% of the provider’s total estimated Medicare Part B Physician Fee Schedule allowed charges

• Must report at least three measures to qualify to earn a PQRI incentive payment.

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Payment models for nutrition services

Private Sector (for covered services):• Practitioner fee schedules for provided service (fee for service)

- Health plans set up provider fee schedules. - Once the RD is credentialed with a health plan, RDs

receive fee schedule for applicable nutrition/nutrition-related services

• Access programs - Discounted rates set by the health plan. Patient pays

for service, not the plan. [Albarado M. “Understanding and negotiating access contracts with insurers and complementary networks.” J Amer Diet Assoc., 2002, Volume 102. Issue 2, pages 187-189.]

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Additional Payment Models

Ambulatory Payment Groups • A methodology developed for and used by Medicaid (and some private BCBS plans) to pay for outpatient procedures performed in hospitals or freestanding facilities.

• Medicare has adopted a similar methodology for payment for certain outpatient services (Part B) called Ambulatory Payment Classification. [MNT not part of Medicare’s APC payment methodology]

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Additional Models of Care (that may impact payment)

Patient-Centered Medical Home• Not a house, hospital or other building and should not be confused with home-health or home-care.

• A model for care provided by physician practices to strengthen the physician-patient relationship. Replaces episodic care based on illnesses and patient complaints with coordinated care and a long-term healing relationship.

• The physician-led care team is responsible for providing all the patient’s health care needs and, when needed, arranges for appropriate care with other qualified physicians.

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Patient-Centered Medical Home-RDs need to be involved locally

Health care reform has provisions for medical home- RD opportunities

Local opportunity to work with medical societies involved in this model of care

• Iowa Department of Public Health charged with developing a Medical Home Advisory Council to develop recommendations regarding a plan for implementation of a statewide patient-centered medical home system- will start with Medicaid

ADA web page Medical Home resourceswww.eatright.org- go to Members, then Practice, then Medical Home

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Monitor Payment Systems

The government and other health plans are looking for payment models to control (reduce) costs while improving quality of care

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MNT Coverage Medicare •Coverage for diabetes, gestational diabetes, chronic kidney disease and post-kidney transplants

• Health care reform--- under negotiation

Private plan coverage• Considerable variability. Check payer policies http://www.eatright.org/coverage/(go to Practice Management, then coverage for nutrition services)

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MNT Advocacy Strategies

• Health plans– Coverage medical director– Wellness/health promotion director– New products director

• Employers

• Healthcare professional’s support- Physicians-Consumers (testimonials)

•Legislator’s support

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ADA Resources… to Market and Promote MNT Services

Third Party Payer Brochure: For Private Payer CEOs, Medical Directors and Provider Relations executives

MNT Works Kit: A marketing tool designed to increase MNT coverage and consumer access to MNT services provided by RDs

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ADA Guide to Private Practice: a resource for any RD considering private practice. New edition to be released this fall

ADA state dietetic association & DPG reimbursement representatives: to assist RDs with local coverage and coding issues

Monica Lursen-- Iowa reimbursement representative

ADA Resources For Your Practice

RD Opportunities- What’s in it for You?

• Payment for MNT • Maintain or expand staff (FTEs)• Business opportunities • Recognition within healthcare

marketplace• Pay for performance (bonus)

Opportunities & Involvement

•Politics is our business- Coverage decisions

•Collaboration to establish local programs

- Patient-centered medical home

•Accountability and Compliance- Understand codes, billing procedures- Monitor and follow up

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PMichael@eatright.org