Private Practice:
Understanding Forms,
Codes, and Insurances!
Amy Cartwright, MS, RD, LDN
Private Practice Dietitian
GOALS

This session will help you to:
– Understand the steps involved in
becoming a credentialed provider with
insurance companies
– Learn codes that RD’s can use to
be reimbursed for their services
– Properly fill out an insurance claim and
appeal denials.
Where to start



As recent studies have shown the importance of
diet in both preventing and managing disease,
many insurance companies have moved toward
providing a nutrition and/or weight management
benefit for its members.
Determine whether or not you want to accept
insurances in your private practice
Identify which insurance companies are popular
in your area.
Next Step

National Provider Identifier (NPI)
– A number that uniquely identifies health
care providers
– Apply at
https://nppes.cms.hhs.gov/NPPES/Welco
me.do
– Can take up to 2 wks to receive #
– This # is necessary to be credentialed
with insurance companies
Next Step

Credentialing with Insurance Companies
– Contact local insurance companies to
determine if they credential Registered
Dietitians
– Credentialing can take up to 2 months
– Determine if you want to be a Medicare Part
B provider or “Opt Out”
– Successfully credentialed with First Priority
Health/Life, Aetna, Federal Employees
Program
Insurance Companies
– Each insurance company has their own
guidelines as to what they cover and how
much will be reimbursed.
– Example: One policy may allow for 24
units to be covered per calendar year (a
unit is 15 min) while others only allow 2-3
visits per year.
– Verifying a patient’s insurance coverage
for MNT will increase your billings and
decrease a large bill for the patient.
The Council for Affordable
Quality Healthcare- CAQH



https://upd.caqh.org/oas/
An online service intended to eliminate the
need for multiple insurance credentialing
submissions
Benefits:
– Saves time!
– Reduces paperwork
– Keeps your information current
– And it’s FREE!
Codes and Coverage




RD’s have fought for many years to have
reimbursable services
The effort continues- as we break through one
glass ceiling another one seems to appear!
January 2002- Medicare started reimbursement
for DM and Renal Disease
January 2008- BCNEPA covers MNT for all
disease conditions including obesity
– Benefit consists of MNT with a Licensed RD for a
maximum of six visits with a $10 co-payment
per contract year
Codes and Coverage

MNT CPT codes describe the
procedure or service provided by RDs
– 97802: MNT, initial assessment and
intervention, individual, face-to-face, each 15
minutes
– 97803: MNT, reassessment and intervention,
individual, face-to-face, each 15 minutes
– 97804: MNT, group, 2 or more individuals,
each 30 minutes
Diagnostic Codes



ICD 9 Diagnosis codes describe an
individual's medical condition and are
required on insurance claims
These codes must match the referring
physicians diagnosis
These codes are updated periodically and
can result in a claim denial if the code is
wrong on your claim
ICD 9 Codes
 Diabetes mellitus

– 250.00: type II or unspecified type, not
stated as uncontrolled
– 250.01: type I [juvenile type], not stated as
uncontrolled
Chronic Kidney Disease
– 585.3: chronic kidney disease, Stage III
(moderate) GFR (30-59)
– 585.4: chronic kidney disease, Stage IV
(severe) GFR (15-29)
Additional Codes



278.00: Obesity, unspecified as defined by BMI
between 30.0 and 38.9
278.01: Morbid obesity or severe obesity as
defined by increased weight beyond limits of
skeletal and physical requirements (125% or
more over IBW), as a result of excess fat in
subcutaneous connective tissues or BMI greater
than 39
278.02: Overweight as defined by BMI between
25 and 29.9
Filing Insurance Claims

You may bill the insurance company for your
face-to-face time with the patient.
– 15 minutes= 1 unit
– Must bill/charge the insurance company the
same fee for all clients that receive the same
service
– Insurance companies have their own fee
schedule which can be found in your signed
agreement with them and can be negotiated
Filing Insurance Claims

CMS-1500 is the standard claim form
– Paper claims are rarely used however it is
important to know what each section
means

– Electronic filing uses the CMS 1500 as a
template for all claims
Electronic Filing websites
– http://www.officeally.com/
– http://www.navinet.net/
Reasons for Denials

Error on claim
– Make sure all required boxes are filled in

No coverage
– Verifying benefits prior to visits is
important

No referral
– Must get referral from physician with a dx
Denials- Example



A policy may only pay for Nutrition Therapy for
Diabetes 250.00, but the patient was referred
for Morbid Obesity 278.01.
The insurance will not pay for the claim if you
use Morbid Obesity as your ICD code when
billing.
If you file the claim with a Diabetes code and
they ask for documentation including the
Physician’s referral and it is not documented
that the physician referred that patient for
Diabetes and that you discussed their diabetes
with them in your notes, this claim will be
denied.
Denial or Unprocessable
claims




Review written notification from the
insurance company describing the reason
for the denial
You may have a deadline for your response
Collect all the documentation about your
claim and your relationship with insurer
Ask the insurance company to provide you
with any notices that they have changed
their policy of accepting claims under the
codes you have submitted.
Denials cont

Consult with other registered dietitians
in the immediate area to see if they
have faced this same problem and
what outcome was reached
Resources




www.eatright.org/mnt
NE Nutrition Entrepreneurs DPG
http://www.nedpg.org/
https://nppes.cms.hhs.gov/NPPES/Wel
come.do
https://upd.caqh.org/oas/
THANK YOU!