REIMBURSEMENT ESSENTIALS
Sarah Butler, MS, RD, LDN
Director of Reimbursement, MDA
Registered Dietitian, Boston University Sargent Choice Nutrition Center
Agenda
• Steps required to be eligible to bill for nutrition services
• Private Insurance
• Government Insurance
• Resources
Before you begin this process
• Must officially be an
RD
• In the state of
Massachusetts must
have completed the
licensure process
• Information about
licensure can be found
here.
Let’s take a look at the
information available in
the “Coding, Coverage &
Compliance tab
Join the Reimbursement
Community to be in the
“know” regarding the ever
changing reimbursement
environment
• A place to ask reimbursement questions
• Network
• Share ideas
• Practice management tips related to reimbursement
• Exchanging best practices ideas to advance
coverage
• Cannot discuss information about the fees you collect
Example of interaction within community
Let’s take a look at
the billing resource
guide for RDs
MNT Coverage
Chart is a good
resource
National Provider Identifier (NPI)
• 10-digit number – similar to a social security number
• Each time you credential with an insurance company they
will attach your NPI to your name and specialty
• Your NPI will remain with you regardless of your job,
location or name changes
• Adoption mandated by HIPAA to improve the efficiency
and effectiveness of electronic transmission of health
information
• Use NPI:
• Each time you call an insurance company to verify benefits
• Each time you file a claim
• Some medical record systems utilize NPI as part of signature
NPI logistics
• No fee to obtain a NPI
number
• Registration tips
• Assure you have plenty of time
to complete process – cannot
save
• Generally will receive NPI
number within 10 days
• Apply for NPI here:
• https://nppes.cms.hhs.gov/
Credentialing with Insurance Companies
• You want to start the credentialing process at least six
months prior to seeing your first patient
• Which insurance companies should you credential with?
• Which companies are popular in your area?
• Ask other RDs in practice about their experience with insurance
companies
• Work on only two insurance companies at a time
• Each has a different process and working on too many at once is
overwhelming and can lead to mistakes
Council for Affordable Quality Healthcare has
been developed to facilitate credentialing and
re-credentialing process
Council for Affordable Quality Healthcare
(CAQH)
• The CAQH Universal Credentialing Datasource:
https://upd.caqh.org/oas
How does CAQH Work?
• RD enters the data required for credentialing application
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into the CAQH secure on-line database
RD faxes (or emails scanned images) of necessary
licenses, pages requiring signatures, liability insurance
contracts etc.
RD will contact insurance company who they are applying
to become credentialed with and ask that they send your
credentialing information to CAQH
Insurance company registers this application with CAQH.
CAQH distributes this information to insurance companies
who either approve or deny the application
Why work with CAQH
• Saves a significant amount of time
• Minimizes paperwork
• Health plans traditionally require providers to update credentialing
information every two or three years
• CAQH makes it easy – once you are all set up you wouldn’t even
realize the health plans are going through the re-credentialing
process
• Keeps information current
• CAQH will ask you to re-attest your information on a regular basis
• Only need to change information that may have changed
• Update scanned images of licenses, liability insurance, etc
• Keeps health plan records and directories up to date
• No fee for this service
Other things to explore
• Employer Identification Number (EIN)
• If in private practice  whether or not to remain sole
proprietor under your SSN
• Professional Liability Insurance
• Completing the W9 form
• If approved by the insurance company how to know
whether to approve the contract
View billing guide for RDs found on the
Academy’s page on “Coding, Coverage
& Compliance”
Insurers and Nutrition Coverage
• Within same insurance company and same type of plan
the nutrition coverage can be completely different
• Insurance rates, plans etc are all negotiated between the
insurance company and the employer who is providing
insurance to their employees
• Result is lots of variation in diagnoses covered, # of sessions
covered, co-pay amount that the patient is responsible for
Factors to consider
• Some policies reimburse RDs individual
• Some policies require RD is performing nutrition services
in a primary care physicians office
• Referrals may be needed
• Special requirements – mainly diagnosis codes
• Variations in patient benefits
• Copayments
• Deductible
• Limits on # of visits
• What is covered?
• See MNT Coverage Chart on the Academy website
Current Procedural Terminology (CPT)
Codes
• CPT codes are numbers assigned to every task and service a
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medical practitioner may provide to a patient
Used by insurers to determine the amount of reimbursement
that a practitioner will receive by an insurer
Code set is maintained and copyrighted by the American
Medical Association (AMA) and has been adopted by the
Secretary of Health and Human Services as the standard for
reporting physician and other services on standard transactions
These are the typical billing codes accepted by most insurance
companies including federal and state programs such as
Medicare and in some cases Medicaid.
Check with the payer to verify CPT codes to use on claims
CPT Codes
• 97802: Medical Nutrition Therapy; initial assessment and
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intervention, individual, face-to-face with the patient, each
15 minute unit
97803: Re-assessment and intervention, individual, faceto-face with the patient, each 15 minute unit
97804: Group (2 or more individuals) each 30 minute unit
Example  If you met with patient for 1 ½ hour initial
consult use procedure code 97802 x 6 units
NOTE: time spent preparing for visit or any pre- or postvisit activities are not considered billable hours and should
not be reported on the claim
Healthcare Common Procedure Coding
System (HCPCS)
• HCPCS codes have been established by the Center for
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Medicare & Medicaid Services
Primarily represent items and supplies and non-physician
services that are not covered by the AMA CPT codes
Medicare, Medicaid, and private health insurers may use
HCPCS procedure and modifier codes
Examples:
S9465: Diabetic management program, per dietitian visit
S9470: Nutritional counseling, per dietitian visit
International Classification of Diseases,
Clinical Modification (ICD-9) or Diagnosis
Codes
• Classification used in assigning codes to diagnoses associated
with inpatient, outpatient, and physician office utilization in the
US
• Every health condition can be assigned to a unique category
and given a code, up to six characters long
• When filing claims you need to check inusurance policy to
determine if coverage is available for the condition (ICD code)
for nutrition services
 “If medical diagnosis is not available from physician RD
should use best available information to determine diagnosis
code. Use of diagnosis code on a claim does not constitute a
medical diagnosis by an RD for legal purposes.”
Referral Systems in Ambulatory Care – Providing Access to the Nutrition Care Process – Academy of Nutrition & Dietetics
Examples of Common ICD-9-CM Codes
• 307.1 – Anorexia Nervosa
• 307.51 – Bulimia Nervosa
• 307.50 – Eating Disorder Unspecified
• 579.0 – Celiac Disease
• 278.0 – Obesity
• 278.01 – Morbid Obesity
• 256.4 – Polycystic Ovarian Syndrome
ICD-9 Codes  ICD-10 Codes
• Effective October 1, 2014 the ICD-9 code sets will be
replaced by ICD-10 code sets
• To stay up to date see: www.cms.gov/ICD10
Common Private Insurance Companies in
Massachusetts
• Blue Cross Blue Shield
• Harvard Pilgrim
• Tufts Health
• Aetna
• Fallon Community
• United Healthcare
Exploring Medicare & Medicaid
MNT Provider
Newsletter is a
fantastic resource
Medicare
• Federal health insurance program for people age 65 and
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older, people of any age with permanent kidney failure
and certain disabled people under age 65.
Managed by the Centers for Medicare & Medicaid
Services, part of the Department of Health & Human
Services
Medicare Part A (Hospital Insurance)
Medicare Part B (Medical Insurance)
DSMT Recognized Program Information
Government Insurance
• Medicare/Medicaid
• Diabetes
• Chronic Kidney Disease
Obesity
• Effective November 29, 2011 Medicare covers screening and
intensive behavioral counseling for obesity by primary care
providers in primary care settings for Medicare beneficiaries with
BMI ≥ 30.
• CMS does not preclude Primary Care Practitioners from referring
eligible beneficiaries to other practitioners for counseling, however,
coverage remains only in the primary care setting.
Cardiovascular Disease
• Effective November 9, 2011 Medicare covers an annual
visit for intensive behavioral counseling for cardiovascular
disease to promote a healthy diet
• Limits this service to the primary care setting
• RDs should work collaboratively with primary care
providers to provide counseling, however, the services
would be billed under the physician
Annual Wellness Visit (AWV)
• As a result of the Affordable Care Act, within 12 months of
enrolling in Medicare Part B, new Medicare beneficiaries
are eligible for a one time “Welcome to Medicare Visit”
• Annual wellness Visit can be billed annually provided 11
full months has passed since the last visit for these
services from the physician/practice.
Who Can Provide AWV Service
• The Centers for Medicare & Medicaid Services (CMS)
allow the AWV to be provided by:
• physicians (MD or DO)
• physician assistants, nurse practitioners, clinical nurse
specialists
• medical professionals (health educators, registered
dietitians, or nutrition professionals, or other licensed
practitioners) or a team of such medical professionals,
working under direct supervision of a physician
Direct Supervision
• CMS defines “direct supervision” as follows:
• “Direct supervision in the office setting means the
physician must be present in the office suite and
immediately available to furnish assistance and direction
throughout the performance of the procedure.” The
physician does not need to be in the room when services
are provided. If an RD is going to provide all or part of
the AWV, he or she must be present in the physician’s
office during this visit.
Initial AWV – Required Components
• Health risk assessment
• Medical/family history
• Measurement of height, weight, body mass index, blood
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pressure and other routine measurements as deemed
appropriate
A list of current providers and suppliers
Screening for cognitive impairments
Screening for depression
Assessment of functional status
Establishment of a written screening schedule
Establishment of a list of risk factors and conditions for which
treatment is being received or recommended
Personal health advice and appropriate referrals for education
or preventive services
Initial AWV – Billing and Coding
• RDs cannot directly bill for the service; the service must
be provided under "direct supervision" of the physician
• Billed using code G0438
• Can be billed once in a beneficiary's lifetime
• No specific diagnosis codes are required, but one must be
included on the claim. Medical providers should choose
an ICD-9-CM diagnosis code or contact the local
Medicare Administrative Contractor for appropriate
guidance.
Subsequent AWV
• Required Components of the Subsequent AWV:
• Subsequent AWV services include updates to the key elements
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of the Initial visit.
Billing and Coding the Subsequent AWV:
RDs cannot direct bill for the service; the service must be
provided under "direct supervision" of the physician
Billed using code G0439
Can be billed annually provided that 11 full months have
passed since the last AWV (dates of service must occur on or
after January 1, 2012)
No specific diagnosis codes are required, but one must be
included on the claim. Medical providers should choose an
ICD-9-CM diagnosis code or contact the local Medicare
Administrative Contractor for appropriate guidance.
Enrolling for Medicare
• RD can apply to become a Medicare Part B provider by completing
the necessary enrollment application forms
• CMS 855I Form
• Other Forms
• Health Care Providers that will bill Medicare carriers (CMS 855B): health
care providers that have formed a practice together and will bill Medicare as a
single provider
• Individual Reassignment of Benefits (CMS 855R) RD submit reassignment
enrollment form if employed at a clinic or facility that will submit Medicare Part
B claims forms and collect payment on behalf of the RD
RDs who do not enroll in Medicare Part B will have to refer
qualifying clients to RDs who are enrolled as Medicare
providers
Medicare MNT Coverage
• Academy is actively lobbying to have Pre-Diabetes
covered
Health Reform
• New Reimbursement Models
• “favor hospital and physician alignment, including physician employment,
over the traditional private practice model.”
• Bundled payments, ACOs, PCMH
• Great incentives for PCMH
• Increased primary care reimbursement rate
• Hospitals may be looking to buy primary care practices
• Hospitals will be penalized for readmissions
• New Coverage
• Medicaid: ~40% increase from 2010-2019
• Health Insurance Exchanges: 24 million
PwC “Health Reform: Prospering in a Post-Reform World.”
Reform Impact on RD?
• “Each sector will feel direct impacts from the
new law and during the months following the
signing of the legislation, many people may
ask, “What does this mean to me?” – PwC
report
• Decrease in fee for service
• Will the RD be more attractive?
• Will these be covered?
• Skype Based Visits
• Telephone Coaching
• Use of smart phones
Tracking Your Outcomes
• Helps support public policy
• Helps with referrals
• Makes you feel good!
Academy Resources
• Coding, Coverage & Compliance
• http://www.eatright.org/coverage/
• Medicare MNT
• http://www.eatright.org/mnt/
• MNT Reimbursement Community of Interest
• Nutrition Entrepreneurs DPG
• http://www.nedpg.org/
• Marsha Schofield, MS, RD, LDN
• Director, Nutrition Services Coverage
• mschofield@eatright.org. 800-877-1600, ext. 4787
Massachusetts Resources
• Massachusetts Dietetic Association
• http://www.eatrightma.org
• Legislation & Advocacy  Reimbursement
• Reimbursement Committee
Resources
• Centers for Medicare & Medicaid Services
• https://nppes.cms.hhs.gov/NPPES
• National Provider Identifier (NPI)
• https://nppes.cms.hhs.gov/NPPES
• CAQH Universal Provider Datasource
• http://www.caqh.org
• Books
• Linda Arpino: Rise to Success Nutrition Practice
Manual
• Ann Silver; Making Nutrition Your Business: Private
Practice and Beyond
Thank You!
• Questions?
• If questions come up later…
• Email: scbutler@bu.edu
• Office: 617-358-5064
References
• 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).
• “Health Reform: Prospering in a Post-Reform World.”
PricewaterhouseCoopers, Health Research Institute, May
2010.
• The Academy of Nutrition & Dietetics, eatright.org