ReimbursementNutr 564: Summer 2007

Objectives Define terms Describe the function of

reimbursement Review strategic planning for

reimbursement Describe components

Covered services Mechanisms

Review examples

Terms Participating Provider

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

Terms Health Care Provider (HIPAA)

Any provider of medial or other health services, or supplies, who transmits any health information in electronic form in connection with a transaction for which standard requirements have been adopted.

Note – as of 2003 Medicare is prohibited by law from paying paper claims except for small providers

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

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

manages the payment

Terms

Center for Medicare and Medicaid Services (CMS) Largest health insurance program 40 million Americans Eligibility

65 years of age or older Some disable persons < 65 End-Stage Renal Disease with dialysis or

transplant

Terms - Medicare

Part A Hospital Insurance Funded by SS

Part B Supplemental Medical Insurance Doctor appointments Other services and supplies Funded by General Revenues and

Premiums

Terms - Medicare

Part C Programs that might help an individual to

pay health care costs that Medicare does not cover

Part D Prescription drug costs

Terms - Medicare

Title XIX of the Social Security Act - law in 1965

Administered by the States

Medicaid

Medicaid is a state administered program and each state sets its own guidelines regarding eligibility and services. http://www.cms.hhs.gov/medicaid/consumer.asp

Terms

Eligibility Low income families with children Aged, blind, disabled individuals who meet

criteria Infants born to Medicaid eligible pregnant

women Children < 6 and pregnant women at <

133% of the Federal poverty level Recipients of adoption assistance and

foster care Certain Medicare beneficiaries

Medicaid

Medicaid Each of the States:

Establishes its own eligibility standards

Determines the type, amount, duration, and scope of services

Sets the rate of payment for services; and

Administers its own program

Terms

‘Medigap’

Insurance that covers expenses outside of Medicare

Terms

What are the issues around reimbursement that warrant the inclusion of this topic as a knowledge and skill for the DPD?

Why??

Reimbursement

What needs to be in place for successful reimbursement?

Reimbursement

History – how has the profession evolved?

Components Covered Services under CMS (Nov ’06)

Medicare covers MNT services when: Ordered by an MD Conditions

Kidney disease not on dialysis Kidney transplant Diabetes

May be provided by RD ‘Medicare approved nutrition professional’

Include: Nutritional Assessment Counseling

Billing systems to connect the service to the compensation

Documentation system - Authorization Documentation of nutrition risk Care Pathways

* Diagnosis

* Age

* Guidelines

Mechanisms - Systems

Standards Who are qualified professionals to

provide the service? RD Credential

Continuing Education

Regulatory oversight - Dept of Licensing

Mechanisms - Billing

Documentation system - INPUTIdentifies the type of service provided

Nutrition Counseling

Identifies the scope of the intervention

Initial Assessment

Follow-up

Identifies the duration

15 min intervals

Mechanisms - Billing

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

Mechanisms - Codes

ICD codesInternational 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

Mechanisms - Codes

ICD codesExample

250 codes for diabetes

Physician sets the diagnosis

Urbanski P: 2001

Mechanisms - Codes

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 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 - Examples 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 - Examples

New CPT Codes for MNT97802 = 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 - Examples

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 process

See 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

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

Wojtylak FR: Medicare enteral and parenteral reimbursement: requirements for successful coverage and payment. Support Line 8/06

Regulations - Examples

Matching Funds for Medicaid

What are the three options for Medicaid disease management? (Pritchett; JADA 04)

What does the chronic care model provide as a framework?

Enteral Documentation - Medicare

Method of administration (e.g., pump, syringe) Appropriate diagnostic codes Ongoing proof of delivery (supplier delivery

records) Ongoing proof of patient compliance (regular calls

and clinician monitoring records/assessments) Copy of CMN (enteral CMN) on file Reasons for the need/use of any specialty enteral

formulas

Additional Issues in Enteral Feeding Specialized formulas need additional

documentation Inadequate documentation may mean

a lower level of reimbursement ‘Down-coding’

Parenteral Coverage

Conditions that do NOT qualify for PN under Medicare

Swallowing disorders Temporary gastric emptying Impaired nutrient intake Anorexia related to metabolic disorder (e.g.

cancer) Impaired oral intake of food with physical disorder Adverse effects of pharmacotherapy End-stage renal disease

When Claims are denied