1. Review of Codes, Coverage Trends and Advocacy Resources Pam Michael, MBA, RD Director, American Dietetic Association Nutrition Services Coverage Team

2. 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 2

3. 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. 3

4. 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). 4

5. Examples of ICD-9 Diagnosis Codes Chronic Kidney Disease (CKD) - 585.X must include a 4 th 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 4 th digit which indicates the type of complication, and must include a 5 th 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 5

6. Coming in 2013: ICD-10CM 6 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 F or 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.)

7. 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 7

8. 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 8

9. MNT CPT Codes 97802 MNT initial assessment and intervention, individual, face- to-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. 9

10. HCPCS MNT “G” Codes G0270 MNT re-assessment and subsequent intervention(s) following 2 nd 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 10

11. 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 11

12. 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. 12

13. 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. 13

14. 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/http://www.cms.hhs.gov/ESRDPayment/ 14

15. 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. 15

16. 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.] 16

17. 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] 17

18. 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. 18

19. 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 resources www.eatright.org-www.eatright.org- go to Members, then Practice, then Medical Home 19

20. Monitor Payment Systems The government and other health plans are looking for payment models to control (reduce) costs while improving quality of care 20

21. 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) 21

22. 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 22

23. 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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26. 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

27. 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)

28. 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 28

29. PMichael@eatright.org