What's New in Coding, Billing, Reimbursement, and Avoiding Litigation Marsha Schofield, MS, RD, LD, FAND Director, Nutrition Services Coverage 3/24/2015 Disclosures I have no commercial relationships to disclose relevant to the topic being presented. Objectives How do I become a provider with third party payers and successfully bill for nutrition services? What s happening in health care delivery and payment? What are the new opportunities and how might I seize them? What is my risk for liability in providing nutrition care and how do I protect myself against such risk? 3 1
4 5 The question Who in my state pays for MNT services provided by registered dietitian nutritionists? 2
The answer It s complicated State Health Insurance Marketplace Medicare: MNT FAQ: What services are covered by Medicare when billed by a Registered Dietitian Nutritionist? Medicare covers MNT for two diseases/conditions: 1. Diabetes mellitus Type 1 and Type 2, gestational diabetes 2. Chronic kidney disease with GFR 13 50 (nondialysis), and kidney post transplant care after discharge from the hospital *No co-pay or deductible 8 Medicare: CPT codes FAQ: What procedural codes are covered by Medicare when billed by RDN? Procedural (CPT) codes are described as: 97802: Medical nutrition therapy; 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. 9 3
Medicare: MNT coverage FAQ: How many visits are covered and what is required by Medicare for MNT services? With a Physician* referral The treating physician must provide a referral each calendar year and for additional hours in same year RDN decides how to schedule time 3 hours in the initial calendar year 2 follow up hours in subsequent years Can use 97802 after 3 years if it is a new patient *Non physician practitioners cannot make referrals for these services 10 Medicare: additional visits FAQ: What if a Medicare patient requires more than 3 or 2 hours in the same calendar year? *RDN must obtain a new physician referral. Procedural (CPT) codes used: G codes should be used when additional hours of MNT services are performed beyond the number of hours typically covered, when the treating physician determines there is a change of diagnosis or medical condition that makes a change in diet necessary. G0270 (Individual each 15 minutes) G0271 (Group each 30 minutes) 11 Medicare: DSMT FAQ: What services are covered by Medicare when billed by a Registered Dietitian Nutritionist? Diabetes Self Management Training (DSMT) Accreditation required 10 hours per calendar year (any increments of 30 minutes) Cannot bill on the same day as MNT services Co pay and deductible apply The following HCPCS codes should be used for DSMT: G0108 Diabetes outpatient self management training services, individual, per 30 minutes; and G0109 Diabetes outpatient self management training services, group session (2 or more), per 30 minutes. 12 4
Medicare: Physician Quality Reporting System (PQRS) FAQ: What is PQRS? For 2015: RDN Medicare providers report on at least 9 measures on 50% of Medicare patients to avoid 2% payment reduction in 2017 Details at www.eatrightpro.org/resource/practice/gettingpaid/nuts and bolts of getting paid PQRS measures and procedures updated annually *Claims reporting; different reporting guidelines apply for reporting via EHR 13 Medicare 2015 PQRS RDN Measures 2015 PQRS Measures Applicable to RDNs: PQRS #1: Diabetes Mellitus: Hemoglobin A1c Poor Control PQRS #128: Preventive Care and Screening: BMI Screening and Follow-up* PQRS #130: Documentation of Current Medications in Medical Record* PQRS #181: Elder Maltreatment Screen and Follow-up Plan Qnetsupport@sdps.com *Denotes a cross-cutting measure 14 Medicare: coverage when incident to FAQ: What services are covered under Medicare when billed by a physician and provided by a RDN? Incident to (under the supervision of a physician): Intensive Behavioral Therapy (CVD and Obesity) Annual Wellness Visit Chronic care management 15 5
Procedure Codes Applicable to RDNs Intensive Behavioral Therapy (IBT) for Obesity G0447: Face-to-Face Behavioral Counseling for Obesity, 15 Minutes G0443: Face-to-Face Behavioral Counseling for Obesity, Group (2-10), 30 Minutes ICD-9 diagnosis codes for BMI 30.0 kg/m 2 or over (V85.30-V85.39, V85.41-85.45) Service can be provided up to 22 times in a 12-month period per CMS schedule RDNs can provide IBT as auxiliary personnel in primary care settings RDNs must bill as incident to physician services (guidelines differ for office-based vs. hospital outpatient clinics) Billable to Medicare; check private payer policies for use of code Learn more at: www.eatrightpro.org/resource/practice/getting-paid/nuts-and-bolts-ofgetting-paid/medicare-preventive-services-obesity 16 Procedure Codes Applicable to RDNs Medicare Annual Wellness Visit (AWV) G0438 G0439 Annual wellness visit; includes a personalized prevention plan of service (PPPS), initial visit Annual wellness visit; includes a personalized prevention plan of service (PPPS), subsequent visit No specific diagnosis codes are required, but one must be included on the claim. RDNs can provide the AWV under direct supervision of a physician (bill as incident to physician services) Learn more at: www.eatrightpro.org/resource/practice/getting-paid/who-pays-for-nutrition-services/annualwellness-visit-in-medicare Procedure Codes Applicable to RDNs Chronic Care Management New! Chronic Care Management Services 99490 Chronic care management services; at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements: Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; Comprehensive care plan established, implemented, revised, or monitored. 6
Medicare: Telehealth FAQ: What Telehealth services are covered by Medicare? MNT, individual and group DSMT, individual and group IBT for cardiovascular disease (must be billed incident to) IBT for obesity (must be billed incident to) Annual Wellness Visit (must be billed incident to) Telehealth Procedural (CPT) codes are described as: The applicable HCPCS/CPT code for the service should be used with one of the following modifiers: GT (via interactive audio and video telecommunications system) GQ (via synchronous telecommunications system applies to demonstration projects in Alaska and Hawaii) 19 The answer Private insurance is not one size fits all Private insurance FAQ: What services are covered by Private Insurance when billed by a Registered Dietitian Nutritionist? Verifying Coverage is vital to ensuring reimbursement Prior to visit: Call the 800 number with patient s insurance ID # and date of birth 7
The Alliance for a Healthier Generation; Healthier Generation Benefit Alliance Healthier Generation Benefit Prevention, Assessment & Treatment The Alliance for a Healthier Generation convened national medical associations, leading insurers and employers to offer comprehensive health benefits to children and families for the prevention and treatment of childhood obesity. Insurers and employers offer: at least four follow up appointments with a primary care provider at least four visits with a registered dietitian nutritionist Ground-breaking Childhood Obesity Benefits Today, over 2.4 million children have access to the Healthier Generation Benefit 24 Hour Fitness Aetna (via select employers) Accenture Anthem Virginia Blue Cross Blue Shield North Carolina Blue Cross Blue Shield Massachusetts Blue Cross Blue Shield Kansas City Capital District Physicians Health Plan Cigna Grand Valley Health Plan Highmark Humana Leviton Nationwide Children s Hospital North Shore Long Island Jewish Health System PepsiCo Sanofi Weight Watchers Wellpoint 8
Private insurance: procedure codes FAQ: What diagnosis codes, CPT codes and number of visits are covered by Private Insurance when billed by a Registered Dietitian Nutritionist? *There is no standard for each insurance company MNT codes: 97802, 97803, 97804, G0270, G0271 MNT codes with 33 modifier 99401 99404 S9470 MNT codes and v codes (for diagnosis code) or 278.00/278.01 when treating obesity under preventive services policy; G0447 for obesity counseling Diagnosis codes, number of visits: coverage varies Private insurance: diagnosis codes FAQ: What diagnosis codes are used for private insurance when billed by RDN? Healthier Generation Benefit/Pediatric Weight Management: V 85.52, V 85.53,V 85.54 codes for BMI V 65.3 Dietary Surveillance and Counseling *sometimes used for preventative along with Modifier 33 Procedure Codes Applicable to RDNs 98960 98962 Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family). 98966 98968 Telephone assessment and management service provided by a qualified nonphysician health care professional. 98969 Online assessment and management service provided by a qualified nonphysician health care professional, internet or electronic communications. 99071 Educational supplies, such as books, tapes, and pamphlets, provided by the physician (or other qualified health care professional) for the patient s education at cost to physician. 99366 and 99368 Medical team conference, with and without the patient and/or family. (Not billable to Medicare; check payer policies to determine use of codes) 9
Procedure Codes Applicable to RDNs Preventive Medicine 99401-99404 Preventive medicine counseling and/or risk factor reduction intervention; individual; 15, 30, 45 or 60 minutes 99411-99412 Preventive medicine counseling and/or risk factor reduction intervention; group; 30 minutes or 60 minutes Used for persons without a specific illness (Not billable to Medicare; check payer policies to determine use of codes) 28 Procedure Codes Applicable to RDNs with Additional Training Based on local scope of practice, state licensure and/or facility requirements, RDNs who pursue additional training to demonstrate competencies may be eligible to provide other billable services, such as: Smoking and tobacco use cessation counseling Training on insulin administration devices Continuous glucose monitoring (check local laws and payer policies) ICD 10: Coming in 2015 FAQ: What is ICD-10? Effective October 1, 2015 claims for services provided on or after this date must use ICD 10 codes (all HIPAA covered entities) Transition to ICD 10 will impact all billing software, forms, and billing procedures Why change? Improve ability to measure health care services Enhance ability to conduct public health surveillance Improve ability to add new codes Align with current medical practices 30 10
ICD 10: Coming in 2015 FAQ: What is ICD-10? Different structure Alphanumeric, 3 7 characters No one to one match between ICD 9 CM and ICD 10 ICD-9-CM Codes ICD-10-CM Codes 250.02 Diabetes mellitus without 311.8 Type 2 Diabetes mellitus with mention of complication, type two or unspecified complications unspecified type, uncontrolled 585.4 Chronic kidney disease, stage IV N18.4 Chronic kidney disease, stage 4 (severe) 31 Is your organization billing? Many organizations may be/have: Not billing for MNT services Cutting out DSMT or outpatient services Medical professionals asking for RDN services but unaware of how to pay for services RDNs may be able to create a plan to support hiring additional RDNs or increased pay/hours Sample questions to ask Billing or Nutrition Department 1. Are we billing for MNT or nutrition services? 2. What insurances are we in-network for? 3. Are you aware that RDNs can bill directly for services? 4. Are you aware that RDNs can bill in office settings? 5. Can we expand our services to other areas (office, outpatient, DSMT, clinics, specialty practices)? 11
Insurance-Where to begin? Preliminary steps to CREDENTIALING 1. NPI 2. EIN 3. Liability coverage 3/24/2015 National Provider Identifier (NPI) A 10-digit number used to recognize the provider on claims transactions. All providers who bill 3 rd party payers must have one (HIPAA requirement) Lasts indefinitely; does NOT contain intelligence Each provider gets ONE NPI, regardless of the number of practice offices. Group practices, hospitals, and corporations get an NPI (see CMS Medlearn article: http://www.cms.hhs.gov/medicareprovidersupenroll/downloads/enrollmen tsheet_wwwwh.pdf Contact the National Plan & Provider Enumeration System NOW! Apply over the Web: https://nppes.cms.hhs.gov/nppes/welcome.do Apply by phone: 1-800-465-3203 (NPI Toll-Free) EIN versus SSN Tax ID number (TIN also known as an Employer Identification number, EIN) It is a nine digit number (9), valid in all states for banking, tax filing and other business purposes (billing insurance) OR Social Security Number (SSN) 12
Become a Qualified Provider Medicare (few weeks) Complete process online: http://www.cms.gov/medicare/provider-enrollment-and- Certification/MedicareProviderSupEnroll/index.html Private payers (6-8 months) Ask for provider relations or the credentialing department. Request a credentialing (enrollment) packet for RDNs. Evaluate alternatives. Consider CAQH enrollment (Council for Affordable Quality Healthcare) http://www.caqh.org/ucd.php Credentialing next steps Choosing which insurance companies to become a provider The first step is to identify which insurance companies are popular in your area. Who will be referring patients to you? Those popular in your area Those most common for the type of practice (if you work in one) Those that are accepted by your area physicians offices Competitive with dietitians in your area Professional Liability Insurance Coverage requirements vary Examples: -minimum of.5 million dollars per claim and 1.5 million dollars aggregate -minimum of 1 million dollars per claim and 3 million dollars aggregate Visit http://www.academypersonalinsurance.com/for details 13
Changing Times in Health Care Fear Uncertainty 40 Comparative Health System Performance Source: the Commonwealth Fund 41 IHI Triple Aim Initiative Improve the health of the population served Improve the experience of the individual Affordability as measured by the total cost of care 42 14
The Good News Focus on Prevention and Primary Care Rescue Street 43 ACA Provisions: Opportunities for RDNs Healthy Aging Employee Wellness & Prevention Child Nutrition School-based health Reducing Childhood Obesity U.S. and Community Preventive Services Task Forces Enhanced Medicare, Medicaid, and Private Plan Preventive Services Medicaid Expansion Home Health Medical Homes 44 What is happening in your state? Essential Health Benefits State Transformation Grants 45 15
Essential Health Benefits 1 2 Required Coverage Categories Under the ACA and Examples of Coverage Maternity Care Includes care before and after a baby is born Rehabilitative and Habilitative Services Includes services and devices that help gain or regain mental or physical skills 6 7 Hospitalization Includes services like surgery Laboratory Services Includes routine blood tests 3 Pediatric Services Includes oral and vision services for patients under the age of 19 8 Prescription Drugs Includes medicine prescribed by a doctor 4 Mental and Behavioral Health Treatment Includes services like counseling and psychotherapy 5 Preventive and Wellness Services Includes services that maintain health, like immunization vaccines 9 10 Ambulatory Patient Services Includes outpatient care without being admitted to a hospital Emergency Services Includes response services to medical emergencies Does not define provider 46 Essential Health Benefits Anthem BCBS KeyCare 30 47 Health Plans and EHBs Exceptions create new mysteries in coverage 48 16
Implications for RDNs Pool of new potential patients/clients Current self-pay patients may now have coverage New patients may represent new demographics Verify benefits/coverage/co-pays/deductibles for existing as well as new patients Verify that you are a provider under the Marketplace Plan Re-evaluate credentialing and contracting opportunities Re-evaluate business plan and payer mix Market your services Contact your affiliate Reimbursement Representative or State Regulatory Specialist to learn about efforts to include MNT/nutrition services and RDNs in your state s benchmark plans New coverage means new patients 49 ACA Coverage: Preventive Services Mandated coverage without cost-sharing in private plans U.S. Preventive Services Task Force (USPSTF) grade A and B Bright Futures pediatric guidelines for prevention and screenings Medicaid Incentives to cover these services with cost-sharing 1% increase in FMAP Medicare Cost-sharing eliminated for USPSTF grade A and B preventive services Annual wellness visit without cost-sharing 50 Healthy diet counseling The USPSTF recommends offering or referring adults who are overweight or obese and have additional cardiovascular disease (CVD) risk factors to intensive behavioral counseling interventions to promote a healthful diet and physical activity for CVD prevention. Grade B Obesity screening and counseling: adults The USPSTF recommends that clinicians screen all adult patients for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss for obese adults. Grade B Obesity screening and counseling: children The USPSTF recommends that clinicians screen children aged 6 years and older for obesity and offer them or refer them to comprehensive, intensive behavioral interventions to promote improvement in weight status. Grade B 17
Implications for RDNs Patients may have more benefits for your services. Verifying benefits gets even more complicated (MNT vs Preventive Benefits); grandfathered vs non-grandfathered plans. No more co-pays for Medicare patients for MNT services. Know the codes (CPT and ICD). Market your services to consumers and referral sources. Advocate with insurers for RDNs as providers of these services. Re-evaluate credentialing opportunities. Expand your role to include Medicare Annual Wellness Visit and Intensive Behavioral Counseling for Obesity Expanded access; expanded roles 52 Shifting Delivery and Payment Models: Do You Speak the Language? Triple Aim Patient-centered medical home (PCMH) Accountable Care Organization (ACO) Population health management Value-based Purchasing (VBP) Pay for Performance (P4P) Fee-for-Service (FFS) Bundled Payments Episode bundles Patient bundles (Global Payments) Parlez-vous health care delivery and payment??? 53 Transforming the System Patient-Centered Medical Homes Medical teams providing coordinated treatment Accountable Care Organizations Network of doctors and hospitals required to provide care for Medicare beneficiaries Center for Medicare and Medicaid Innovation 54 18
Patient-Centered Medical Home A PCMH is not a house, hospital or other building and should not be confused with home-health or home-care. The PCMH is a model for care provided by physician practices that seeks to strengthen the physician-patient relationship by replacing episodic care based on illnesses and patient complaints with coordinated care and a long-term healing relationship. Each patient has an ongoing relationship with a personal physician who leads a team that takes collective responsibility for patient care. 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. National Committee for Quality Assurance 55 Patient-Centered Medical Neighborhood 19
Accountable Care Organization (ACO) An ACO is a high-performing, organized system of care and financing that can provide the full continuum of care to a specific population over an event, episode, or a lifetime while assuming accountability for clinical and financial outcomes Bard and Nugent, Accountable Care Organizations, 2011. 58 Goals of the ACO Efficiency Quality Effectiveness Access Patient-centeredness Equitability 59 ACO Key Issues Bundled Payment : single payment for all care related to treatment or condition Payment is apportioned to multiple providers across many settings 60 20
Changes in Hospital Payments Hospital readmissions reduction program Hospital-acquired conditions (HAC) Hospital value-based purchasing 61 What is happening in your state? Essential Health Benefits State Transformation Grants 62 Transformation in Virginia Virginia awarded Round Two Model Design Award from CMS (December 2014) www.innovation.cms.gov/initiatives/state-innovations/ PCMH and Enhanced Primary Care Teams demonstration projects Public - focus on dual-eligible (Commonwealth Coordinated Care Program) Private Cigna, Anthem, Humana www.pcpcc.org/innitiatives/virginia 63 21
Implications for RDNs Find out what demonstration projects are happening in your area. Market yourself to demonstration projects. Collect and report outcomes data. Develop and/or participate in hospital readmission prevention efforts. Market MNT services as a strategy for reducing hospital readmissions for heart failure patients. To find CMMI funded innovation opportunities in your state: http://innovation.cms.gov/initiatives/map/index.html Be a part of the experiment and prove that MNT works! 64 Vision Based on demonstrated value to individuals and their health-care team, RDNs are essential in personcentered health care delivery models, meeting the individual s health care needs throughout their life cycle. 65 Take Action www.eatrightpro.org: Practice/Getting Paid in the Future Leadership/House of Delegates 66 22
Reaching New Horizons Rethink the value proposition Rethink your role Rethink your message Build your skill set 67 68 Avoiding Litigation Orange is no the new black 23
Malpractice: What is it? Negligence in one s capacity as a professional. Conduct or judgment falls below standards of care for the profession ( reasonable and prudent ) Breach of duty Failure to act Failure to keep current Responsible for damage and harm caused to others, whether intentional or unintentional. No damage, no negligence Applies to all areas of practice 70 Just the Facts How often? At least 14 published decisions with malpractice awards against RDNs in recent years. Frequently catastrophic situations: death as a result of a food allergy or adverse medication reaction. RDNs are saved from many malpractice cases because of intervening cause and respondeat superior doctrines. Lower risk, but growing concern 71 Just the Facts Why? Failure to adequately monitor nutrition in nursing care patients (e.g., unintended weight loss, nonhealing wounds) In home consultations: young children, eating disorders, malnutrition in the elderly Choking Tube feeding refusal Bariatric surgery gone bad Prenatal care Prison system 72 24
Playing it Safe Give good care Update your skills Don t accept an unacceptable job Document, document, document Keep the family happy Give respectful care Protect yourself 73 Academy Resources 74 Academy Resources www.eatrightpro.org/resources/practice/ getting-paid www.eatrightpro.org/resources/practice/ getting-paid-in-the-future 25
Questions 76 26