Transcript Slide 1

Review of Codes, Coverage Trends and
Advocacy Resources
Pam Michael, MBA, RD
Director, 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.X
must include a 4th digit
•
585.4; chronic kidney disease, Stage IV (severe)
[Kidney damage with severe decrease in GFR (15-29)]
Diabetes Mellitus – 250.XX
must 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
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.)
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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
-
Medical, surgical procedures/services
-
Payers-- language of reimbursement
National/International research standardization
• Standardized Uniform Language
• Communications Vehicle
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, faceto-face, each 15 minutes
97803
• 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 Medical
Association. 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-face
services; 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 Medical
Association. 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_ho
spitals.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 Systems
Medicare 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 HomeRDs 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 resources
www.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 Resources For Your Practice
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
RD Opportunities- What’s in it for You?
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•
•
•
•
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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