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Reimbursement. Nutr 564: Summer 2005. 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

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slide1

Reimbursement

Nutr 564: Summer 2005

objectives
Objectives
  • Identify the components of reimbursement
  • Describe the barriers
  • Identify resources for MNT reimbursement
terms
Terms
  • Medigap policy –

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

  • Medicare + Choice

Medicare-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

terms1
Terms
  • Participating Provider

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

terms2
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
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
reimbursement1
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

reimbursement2
Reimbursement
  • Billing systems to connect the service to the compensation
    • Insurers recognize the standards

Example: CAM process

reimbursement3
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

reimbursement4
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

reimbursement5
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

reimbursement6
Reimbursement
  • ICD codes

Example

250 codes for diabetes

Physician sets the diagnosis

Urbanski P: 2001

reimbursement7
Reimbursement
  • Billing systems to connect the service to the compensation
    • Documentation system - Authorization

Documentation of nutrition risk

* Diagnosis

* Age

* Guidelines

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Reimbursement

Nutrition Support

Client not able to take 50% of estimated nutritional needs

Calorie Count or Nutrition Intake Assess

Physician confirmation

Updated to revised periodically

reimbursement9
Reimbursement
  • Billing systems to connect the service to the compensation
    • Documentation system - Submission

ICD codes

reimbursement10
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
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Reimbursement
  • Medicaid is very specific for the states. Cannot compare between states.
reimbursement12
Reimbursement
  • Barriers
    • Insurance Policies
      • Medicaid policies for coverage
      • Private insurers’ practices
        • Should be the same as Medicare or Medicaid
    • Changing regulations
    • Details of submitting a claim
      • ICD codes
    • Lack of systematic feedback / QA
reimbursement13
Reimbursement
  • Professional Activities
    • Support MNT Legislation
    • Keep informed
    • Communicate to your representatives
reimbursement14
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
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
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
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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

reimbursement16
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

reimbursement17
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
reimbursement18
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 process

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

Urbanski P: 2001

cms and opting out
CMS and ‘Opting Out’

Why

A client with an eligible service need

Medicare Provider

Opt Out

cms and opting out1
CMS and ‘Opting Out’

Medicare provider

Pro

  • 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 out2
CMS and ‘Opting Out’

Opt-out

  • Better reimbursement
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