Mary Ann Hodorowicz, RD, LDN, MBA, CDEMary Ann Hodorowicz, RD, LDN, MBA, CDE

Certified Endocrinology CoderCertified Endocrinology CoderMary Ann Hodorowicz Consulting, LLC 2/2013Mary Ann Hodorowicz Consulting, LLC 2/2013

Money Matters in DSMT and MNT: Money Matters in DSMT and MNT:

Increase Your Increase Your

Insurance Reimbursement Insurance Reimbursement NOWNOW!!

LEARNING OBJECTIVES

1.Describe the beneficiary eligibility criteria for Medicare MNT and DSMT

2. List three of the Medicare coverage guidelines for telehealth MNT and DSMT

3.Name the procedure codes used to bill Medicare for

MNT and for DSMT

Medicare MNT--DSMT Reimbursement Rules:COPIOUS, CONVOLUTED, CONFUSING,

COMPLICATED, CONSTANTLY CHANGING!

MEDICARE BENEFICIARY MNT--DSMT ENTITLEMENT

• Must have Medicare Part B insurance• Suggestion: Make copy of Medicare card for MR

DSMTDSMT

General General and basic training in 7 key

behaviors in primarily

groupgroup format

pt’s knowledge of knowledge of

whywhy and skill in howskill in how to

change behaviors

Shorter-termShorter-term follow-up with limited limited monitoring of labs, outcomes, etc.

MNTMNT

IndividualizedIndividualized, detailed and focused nutrition therapy

PersonalizedPersonalized meal plan,

SMBG and exercise plans

Long-termLong-term follow-up in pt’s

life with extensiveextensive monitoring

of labs, outcomes, behavior

and meal plan adjustments

MNT--DSMT: COMPLIMENTARY & DISTINCT

COORDINATION OF MEDICARE MNT--DSMT

fo r period of 36 m onthsafter successfu l k idney transp lant.

M EDICAL CONDITIONSD iabetes: Type 1 , Type 2 , G D M ,N on-D ialys is R enal D isease, and

M NT: First Calendar Year, 3 HrsInd iv idua l or group. Individualized

assessm ent, nutrition dx, intervention (incl. m ealp lan) and m onitoring & eva luation o f outcom es.

*9 hrs o f 10 to be group ; 1 m ay be individual.10 hrs m ay be ind iv idua l if p rov ider's docum entation

of special needs is in D SM T provider's p t chart orno program scheduled in 2 m onths o f re ferra l da te.

N utrition is 1 of 10 top ics presentedas overv iew of basic m eal p lann ing

for BG contro l (not ind ividua lized for p t).

DSM T: 12 Consecutive M onths, 10 Hrs*Group classes* in 10 top ic areas

on basic d iabetes se lf-care outlinedin N ationa l S tandards o f D SM E (2007).

M edicare covers MNT and DSM T but NOT on sam e day!

MEDICARE MNT—DSMT BILLINGBILLING PROVIDER ELIGIBILITY

Separate billing allowed: hosp.OP , nurs ing hom e,E SR D facility , FQ HC, c lin ic, M D /R D practice,

hom e health . N O T allowed: inp t hospita l,rural hea lth clin ic, sk illed nursing facility

L icensed or certified in s ta te w here furnsh ingM NT, if s ta te has law regarding.

C DE status not required.

B S in nurition/die tetics from accred ited school.M in im um 900 hrs o f practica l experience.

R D or N utrition P rofess ional (NP ) w ho isM edicare prov ider and has m et below crite ria:

MNT

Separate D SM E billing NO T allowed: hosp ita l inp t, hosp ice care, nursing hom e,

rural health center, ES RD facility

Entity M edicare providers: D M E, pharm acy, hosp ita l OP dept, clin ic , sk illed nurs ing

fac ility , M D/RD practice, Federa lly QualifiedH ealth C enter, Hom e Health A gency

Individual M edicare providers w ho can b ill onbehalf o f entire program : physic ian, P A, RD , NP

C NS , c linical psychologis t, LCS W . C an also teachbut program m ust have RD or RN or RP h.

S elect ind iv idua l + entity M edicare prov iders can b ill.M ust prov ide and b ill fo r o ther M edicare services

and be d irectly re im bursed. Cannot join M edicarejust to prov ide and bill fo r D S M T.

DSME

My mother taught me about the science of Osmosis…

“Shut your mouth and eat your

supper!”

RD’s OPTIONS: MEDICARE MNT--DSMT

B: Become Medicare provider and BBill Medicare for MNT; can then bill for accredited DSMT program

R:R: RRefer beneficiary for MNT or DSMT to Medicare

RD provider who is furnishing, or to accredited DSMT program

O:O: OOpt out of Medicare by filing opt out affidavit letter

every 2 yrs; enter into private contract with each beneficiary, using Medicare contract language

X:X: eXXclude Medicare involvement and rules for MNT notnot covered by Medicare Part B

MEDICARE MNT--DSMT QUALITY STANDARDS

published byAcadem y of N utrition and D ie te tics (A.N .D .)

and published in A .N .D .'son line N utrition C are M anual

MNTM ust use nationa lly recognized pro toco ls

such as current ev idence-basedN utrition P ractice G uide lines for d isease sta te

P ts in D SM T class m ust s ign a ttendance sheet

D SM T program in R ura l H ea lth C lin ic:If so lo instructor, m ust be R D -C D E.

C M S defines rura l area (w w w .cm s.gov)

Both requ ire adherence toNational Standards of DSM E. Standard 5 :R D , R N or pharm acist can be solo instructor,

bu t m ulti-disc ip linary team recom m ended.

DSMTR equired: recognition o f p rogram by AD bA

or accred ita tion by AAD E. Send copy of certifica teto M edicare carrie r or reg ional M AC , re turn rece ip t.

Help me to always Help me to always give 100% at work…give 100% at work…

12% on Monday12% on Monday

23% on Tuesday23% on Tuesday

40% on Wednesday40% on Wednesday

20% on Thursday20% on Thursday

5% on Fridays5% on Fridays

B est Prac tic e SuggestionU se DSM E/T and M NT Services Order Form

(rev ised 8 /2011) Access a t: w w w .aadenet.org

K idney T ransplant MNTSuccessfu l k idney transp lant.

M N T is in 36 m onths fo llow ing transp lant.

Pre-Dialys is R enal MNTD x docum entation o f 1 o f renal d isease stages

that supports d iagnostic crite ria:S tage III, IV and V C KD

Diabetes MNTN ot rec 'd M N T in past 3 yrs.

D ocum entation o f d iabetes dx us ing 1 o f 3 labs.Physic ian re ferra l for in itia l, f/up, extra hrs.

Benefic iaries in c lass to s ign a ttendance sheet.

D iabetes can be dx 'd prior to Part B entry.P t on rena l d ia lys is on ly e lig ib lefor non-nutrition content areas.

DSMTIn itia l not rec 'd ever before (1/life tim e benefit).

D ocum entation o f d iabetes dx us ing 1 o f 3 labs.Physician/qua lified N PP re ferral for initia l and f/up.

MEDICARE BENEFICIARY ELIGIBILITY for MNT--DSMT

^H bA 1c >/=6.5% d iagnostic fo r T1 , T2 D Mper A D bA , S tandards o f M ed ica l C are , 2012

*Federa l R eg is te r, V o l. 68 , #216, 11-7-03, p .63261

Sym ptom s of unc ontrolled diabetes :E xcessive th irs t, hunger, u rina tion, fa tigue,

b lu rred vis ion , un in ten tiona l w e ight loss,w ound tha t w on 't hea l, e tc.

FP G > /= 126 m g on 2 tests , or2 hr O G TT > /= 200 m g on 2 tests , or

R andom B G > /=200 m g + uncontro lled D M sym ptom (s)H bA 1c not added as o f Feb. 2013 ^

B est Prac tic e SuggestionsO bta in docum enta tion o f diagnostic lab.

U se rev ised D S M E /T--M N T S erv ices O rder Form .D ow nload a t: aadenet.o rg (rev ised 8 /2011)

Pre-Dialys is R enal DiseaseG FR on 1 lab test o f: 13--50 m l/m in.1 .73m 2

S tage III = 30--50, S tage IV = 15--29S tage V = <15

G estational DiabetesP rovider to prov ide docum enta tion ofgesta tiona l diabetes IC D -9 dx code.

T 1 and T 2 DiabetesM edicare s tates tha t T1 , T2 d iabetes is d iagnosed us ing 1 o f 3 tests be low * .

A bove sta tem ent now on revised D S M E /T and M N T S erv ices O rder Form (rev ised 8 /2011).*M NT : O n ly phys ic ian can R x. DSM T : P hysic ians + qua lified N PP can dx (N P , P A , C N S ).

MEDICARE DIAGNOSTIC LAB CRITERIA for MNT--DSMT

MEDICARE MNT--DSMT REFERRAL REQUIREMENTS

R evised DSM E/T and M NT O rder Form lis tsd iagnostic lab crite ria + asks prov ider to send labs

for p t elig ib ility and outcom es m onito ring.O rig ina l to be in pt's chart in p rov ider's o ffice.

D x or code (5 d ig its fo r T1, T2 D M ).P hysic ian 's N P I + s ignature (s tam ped not a llow ed).

Faxed + e-re ferra l a llow ed.S eparate R x fo r: in itia l, f/up M N T and extra hours.

MNTW ritten R x by trea ting phys ic ian.

To inc lude: R x date + benefic iary 's nam e.

For initial: w hether group or ind iv idua l D S M T.If individual: specia l needs that w arrant.

P hysic ian/N P P to m ain ta in p t's p lan o f care inchart m ain ta ined in h is /her o ffice.

D x or code (5-d ig its fo r T1, T2 D M ).P hysic ian's /N P P 's N P I + signature.

S eparate R x fo r: in itia l and f/up D S M T.For initial: top ics + hrs to be taught (10 to ta l each).

DSMTW ritten R x by trea ting phys ician or qua lified

non-physic ian practitioner (N P P): N P , PA ,C N S.To inc lude: R x date + benefic iary 's nam e.

Revised Aug. 2011

WHAT’S DIFFERENT ON REVISED FORM

Added Added Definition of Diabetes (Medicare):Definition of Diabetes (Medicare):

“Medicare coverage of DSMT and MNT requires the physician to provide documentation of a diagnosis of diabetes based on one of the following”:

• FPG >/= 126 mg/dl on 2 different occasions;

• 2 hr PPG >/= 200 mg/dl on 2 different occasions; or

• Random BG >/= 200 mg/dl with symptoms of uncontrolled DM

Source: Volume 68, #216, Nov.7, 2003, page 63261/Federal RegisterOther payors may have other coverage requirements.

WHAT’S DIFFERENT ON REVISED FORM

AddedAdded MNT Telehealth and DSMT Telehealth

Added Added in DIAGNOSIS section:

“Please send recent labs for patient eligibility &outcomes monitoring.”

OmittedOmitted these words in DIAGNOSIS section:

“Uncontrolled” and “Controlled” for Type 1, Type 2

WHAT’S DIFFERENT ON REVISED FORM

Omitted Omitted these sections:

•Current Diabetes Medications

•Patient Behavior Goals/Plan of Care

Are we Are we confused yet?confused yet?

DIETITIAN LICENSURE/CREDENTIALING STATE LAWS for FURNISHING MNT

Laws in states below specifically outline mandates1 re:

• Written physician referral for nutrition services/MNT, or

• Dietitian’s activities based on physician’s order, or

• Physician involvement when treatment/condition is medical

• Provisions for dietitian conduct when physicians involved

Alabama Indiana Connecticut Tennessee California

Illinois Florida Massachusetts Maine South Carolina

1. www.eatright.org/HealthProfessionals/content.aspx?id=6863 Accessed 3-26-12

MARY ANN WILL NOW MARY ANN WILL NOW

ENTERTAIN YOUR QUESTIONSENTERTAIN YOUR QUESTIONS

MEDICARE MNT--DSMT LIMITS in FIRST YEAR and STRUCTURE OF

.

E xam ples o f m edica l necessity:C hange in m edica l condition, diagnosis and/ortreatm ent regim en requ iring additiona l M N T.

A dditional H rs > 3 R eim bursable IF:R D obta ins new Rx which docum ents # extra hrs

to be furnished and m edica l necessity for.

Individual v isit to be >/= to 8 to < /= to 23 m in.(= 15 m in. b illing un it)

M NT: 3 hrs in ca lendar yr.C annot extend into next yr.

Ind iv idua l, group or com bination.G roup v is it to be > /= 30 m in. (30 m in. billing un it).

(language, hearing, physica l, cognitive, etc .)O R no program starting w ith in 2 m onths of Rx date,

O R physician orders additional insulin tra ining.

A dditional H rs N ot Cited by C MS as Payable.9 hrs can be ind ividual IFre ferring providerdocum ents in m edica l record and on R x:

P t's special needs preclud ing group (v ision,

1 hr m ay be for ind ividual assessm ent, insu lininstruction or tra ining on A NY top ic.

10 hrs m ay be used for on ly 1 topic (new!).

D SM T: 10 hrs in 12 consecutive m onths.C annot extend into next yr.

9 hrs group + 1 hr m ay be indiv idualV is it to be > /= 30 m in. (30 m in. billing un it).

Medicare MNT and DSMT in initial year may NOT be provided on same day!

CHANGES THAT MAY JUSTIFY EXTRA HOURS of MEDICARE MNT

DIABETES MNTDIABETES MNT

•Oral meds to insulin

•Lack of understanding of diabetes diet

•GDM pt requires frequent diet changes

•Diabetes complication requiring tighter diet control

NON-DIALYSIS RENAL MNTRENAL MNT

•Significant decrease in renal sufficiency

•Lack of understanding of renal diet

•Onset of malnutrition

•Completes DSMT and develops renal condition

MEDICARE MNT--DSMT LIMITS in FOLLOW-UP YEARS and STRUCTURE OF

.After 3 Yrs from O riginal Initial M NT Visit

B eneficiary m ay be elig ib le for IN ITIALM NT ep isode of care aga in as if has not

rec ieved in past.

Individual v is it: > /= to 8 to < /= to 23 m in.(= 15 m in. b illing un it)

R equired: new R x for f/up, docum entation of dxand reason for f/up.

2 hrs in each calendar yr after firs t.C annot extend hrs to next yr.

Ind iv idua l, group or com bination.G roup v isit: > /= 30 m in. (30 m in. billing un it)

F/Up M NT After First Calendar Year

S peical needs do not need to be docum entedfor ind ividua l f/up D SM T.

C an obta in even if IN IT IAL DS M T not rece ived.

Individual or group v is it: > /= 30 m in. (= 30 m in. billing un it)

R equired: new R x for f/up anddocum entation of d iabetes dx.

2 hrs each calendar yr a fter yr initial com pleted.C annot extend hrs in to next yr.

Ind iv idua l, group or com bination.

F/Up DSMT After First 12 Consecutive M onths

MEDICARE TIMEFRAME CHANGES for FOLLOW-UP DSMT: EXAMPLE

Pt Completes Initial 10 Hrs That Spans 2 Yrs: 2012 and 2013:• First visit in April 2012 • Completes initial 10 hrs in April 2013• Eligible for f/up in May, 2013

• Completes f/up in Dec., 2013

• Eligible for next yr f/up in Jan., 2014

Pt Completes Initial 10 Hrs in Same Calendar Year: • First visit in April 2012

• Completes initial 10 hrs in Dec., 2012

• Eligible for f/up in Jan., 2013

• Completes f/up in July 2013• Eligible for next yr f/up in Jan. 2014

DIAGNOSES for MEDICARE MNT--DSMT

S elect profess ionals authorized to select IC D-9 codes for narra tive diagnosis:

PHYSIC IANS, QUALIFIED NPPs andLICENSED MEDICAL RECORD CODERS

O n CLAIMS , use 5 d ig it code w hen possible:250.02 = Type 2 uncontro lled diabetes

vs. 250 = d iabetes m ellitus.Claim m ay be denied if 5th digit not used

O n REFERRAL and in M R , d iagnosis can benarrative description OR IC D-9 dx code

Diagnosis is Required Docum entation: 1) In M R m ainta ined by educator/RD

2) In M R m ainta ined by physic ian/NPP

DIAGNOSES for MEDICARE MNT-DSMT

4th digit = clinical manifestation/complication of diabetes

250.0 Diabetes mellitus without mention of complication

250.1 with ketoacidosis

250.2 with hyperosmolarity

250.3 with other coma

250.4 with renal manifestations

250.5 with ophthalmic manifestations

250.6 with neurological manifestations

250.7 with peripheral circulatory disorders

250.8 with other specified manifestations

250.9 with unspecified complications

DIAGNOSES for MEDICARE MNT--DSMT

• 5th digit identifies:

• T1 or T2 diabetes• Controlled or uncontrolled

250.X00 Type 2 controlled

250.X11 Type 1 controlled

250.X22 Type 2 uncontrolled

250.X33 Type 1 uncontrolled

PROCEDURE CODES REQUIRED by MEDICARE and COMMONLY ACCEPTED by

PRIVATE PAYERS

C PT® = C urrent P rocedura l Term inology C odes; copyright, Am erican M edica l Associa tionH C PC S® = H ealthcare C om m on P rocedure C oding System ; m onitored, m ainta ined by C M S

H CPC S® Codes for Hrs B eyond Lim it:2nd R x, sam e yr, Ind iv id : G0270 (1 un it = 15 m in)2nd R x, sam e yr, G roup: G 0271 (1 un it = 30 m in)

In itia l o r E stablished P t

Follow-Up V isits:Indiv idual, est. p t: 97803 (1 unit = 15 m in)G roup, est. p t: 97804 (1 unit = 30 m in)

C PT® * Codes for Initial Visit:Indiv idua l, new pt: 97802 (1 un it = 15 m in)

U sed only 1 tim e for initial v is it in first yr G roup, new pt: 97804 (1 unit = 30 m in)

MNT

P rivate payers m ay requ ire these or other codesor the ir unique codes identified

in payer-provider contract.

H CPC S® * Codes for Initial + Follow -U p V isits:Ind iv idua l: G 0108 (1 un it = 30 m in)G roup: G0109 (1 un it = 30 m in)

DSMT

MEDICARE REQUIRED MNT--DSMT CODES

Visit can be any # of units but must be Visit can be any # of units but must be >> 1 1 1 Unit1 Unit

97802 MNT, initial episode of care (EOC), individual 15 min

97803 MNT, f/up EOC, individual 15 min

97804 MNT, initial or f/up EOC, group 30 min

G0270 MNT, initial, individual, beyond 3 hrs or MNT, f/up, individual, beyond 2 hrs per 2nd referral in same yr

15 min

G0271 MNT, initial, group, beyond 3 hrs or MNT, f/up, group, beyond 2 hrs per 2nd referral in same yr

30 min

G0108 DSMT, individual, initial or f/up, each 30 min. 30 min

G0109 DSMT, group, initial or f/up, each 30 min. 30 min

CMS’ GUIDE for 15 MIN. TIME-BASED CODES

UNITS UNITS MINUTES to MINUTES MINUTES to MINUTES11

1 > 8 < 23

2 > 24 < 37

3 > 38 < 52

4 > 53 < 67

5 > 68 < 82

6 > 83 < 97

7 > 98 < 112

8 > 113 < 127

1. www.cms.gov/manuals/downloads/clm104c05.pdf Accessed 3-26-12

Non-Facility: $13.96 - $19.53Facility: $13.67 - $19.16

Non-Facility: $27.26 -- 37.81Facility: $25.20 – 35.27

97804, group, initial or f/up, 30 m in rates:

Adjusted* Rates: 97802, initial, 15 m in:Non-Facility: $31.45 -- 43.71Facility: $29.39 -- 41.17

97803, f/up, 15 m in, range of ra tes:

100% of M edicare P hysic ian Fee S chedule (M PFS ).M edicare pays 100% of ad justed ra te.

20% pt co-paym ent waived, B UT paid by M edicare.

Initia l and F /U p M NT : 2012

Adjusted* Rates:G 0108, ind iv idual, 30 m in: $45.37 – $69.59G 0109, group, 30 m in: $13.67 – $20.98

*R ates vary per geographic region.

100% of condensed M PFS for par prov iders,but on ly 95% for non-par providers.

M edicare pays 80% of ad justed ra te, p t pays 20%

Individual + Group DSM T : 2012

MEDICARE MNT--DSMT REIMBURSEMENT RATES1

1. www.cms.gov/apps/physician-fee-schedule/license-agreement.aspx Accessed 3-26-12

My mother My mother taught me about taught me about contortionismcontortionism

“ “Will you Will you

look at look at

the dirt the dirt

on the on the back back

of your of your neck!”neck!”

.DSM T

Part A hom e health benefitand Part B D SM T can be

received at sam e tim e

DSM TYES separate Part B b illw hen outs ide of Part A

treatm ent p lan on 34x b ill

M NTYES separate Part B b ill

Hom e Health Agency

DSM TN O separate Part B b ill

M NTYES separate Part B b ill but

only for non-d ia l bene 's

End Stage Renal D ialysis Facility

HOME HEALTH AGENCY and ESRD FACILITY MEDICARE MNT--DSMT BILLING

.

U ee 22x, 23x type of b illR evenue code 0942

DSM TYES separate Part B b ill.Part A SN F benefit and

Part B D SM T can be received at sam e tim e

M NTN O separate Part B b ill

Skilled Nursing Facility

DSM TN O separate Part B b ill

M NTYES separate Part B b ill

Nursing Hom e

SKILLED NURSING FACILITY and NURSING HOME MEDICARE MNT--DSMT BILLING

.

DSM TSam e

TO B 73x, revenue code 052x

M NTO nly 1 :1 separate ly b illbable to Part B .

P rovide outside of treatm ent p lan.G roup paid at a ll-inclusive Part A rate

FQ HC

DSM TN O separate Part B b ill.

Pa id at a ll-inclusive Part A rate.Solo instructor to be R D -C D E

M NTN O separate Part B b ill. M ay be

able to b ill incident to .Paid at a ll-inclusive Part A rate.

Rural Health C linic

FEDERALLY QUALIFIED HEALTH CENTER and RURAL HEALTH CLINIC

MEDICARE MNT--DSMT BILLING

MEDICARE MNT--DSMT TELEHEALH

INDIVIDUAL + GROUP MNT-DSMT can be delivered via telehealth1

REIMBURSEMENT: Same as in original MNT-DSMT benefits

WHAT IT IS: Interactive audio & video telecommunications system permitting real time communication + visualization

1. www.cms.gov/transmittals/downloads/R140BP.pdf Accessed 3-26-12

DSMT: >1 hr of 10 in initial yr & >1 hr in follow-up yrs to be furnished in-person for training on injectable medications (individual or group)

Excluded: Telephone calls, faxes, email without visualization, stored and delayed transmissions of images of pt

MNT-DSMT Provider Eligibility:

Licensed or certified in state where provider works AND

in state where patient located

If pt in 1 state and provider location in another, provider must

be licensed or certified in both states

Beneficiary receiving MNT--DSMT must be present and participate in telehealth visit

CPT code modifier “GT” added to MNT—DSMT code on claim:“Interactive audio and video telecommunications system”

Originating Site: Location of beneficiary. To be in NON-metropolitan statistical area (see www.census.gov). Facility fee can be billed

via code Q3014; deductible + coinsurance apply (2012 = $24.10)

Originating Distant Site Site

Eligible Originating Sites: Physician/NPP office*, hospital, CAH,RHC, FQHC, hospital and CAH-based renal dialysis center, SNF,community mental health center. *Bills Part B; others bill Part A

Distant Site: Location of provider at time of service

Excluded: Home Health, independent renal dialysis facilities

MNT--DSMT CLAIM FORMS for for

HOSPITAL and PRIVATE PRACTICEHOSPITAL and PRIVATE PRACTICE

*Institu EC F = Institutional e lectronic cla im **Prof EC F = Professional e lectronic cla im^ If paper c la im used, m ust use new C M S-1500 paper cla im (08-05) and new U B-04 paper c la im .

To Part AIn term ediary; be ing

rep laced by M ed icareAdm in is tra tive C ontractors

C M S 1450= U B04 c la im ^ or H IPAA 837

Institu E C F*

Hospital O P:If H osp ital is

P rov ider:

To Part B C arrie r;be ing rep laced by

M edicare Adm in is tra tiveC ontractors..."M AC s"

C M S 1500cla im or

H IPAA 837Pro f EC F**

PrivatePractice:

R D is provider:

M EDICARE

To P riva teInsurance

C M S 1450= U B04 c la im ^ or H IPAA 837

Institu E C F*

Hospital O P:If H osp ital is

P rov ider:

To P riva teInsurance

C M S 1500cla im or

H IPAA 837Pro f EC F**

Private Practice:

R D is provider:

PRIVATE PAYER

MARY ANN WILL NOW MARY ANN WILL NOW

ENTERTAIN YOUR QUESTIONSENTERTAIN YOUR QUESTIONS

REJECTED vs. DENIED CLAIMS

IN VALID C la im :In fo is illogica l or incorrect

(ex: w rong N P I # , hysterectom ybilled fo r m ale p t, e tc .)

= IN C O M PLETE C la im :R equired in fo is m iss ing orincom ple te (ex: no N P I #).

M edicare re turns as unprocessab le.M edicare cannot m ake paym ent

decis ion until rece ip t ofcorrected, re-subm itted c la im .

REJECTED CLAIM

To pursue paym ent, p rov ider cango through M edicare 's

appea ls process.

M edicare m ade determ ination thatcoverage requ irem ents not m et;

exam ple: serv ice is not m edica llynecessary.

DENIED CLAIM

MEDICARE ELECTRONIC PAYMENTS

•Affordable Care Act mandates Medicare payments be made only via electronic funds transfer (EFT)

– Part of CMS’ revalidation efforts

– Providers not rec’ing EFT payments will be:

• Identified

• Required to submit CMS 588 EFT Form with

Provider Enrollment Revalidation Application

•MACs and clearing houses provide electronic claims software at little/no charge at:

www.cms.hhs.gov/ElectronicBillingEDITrans/08_ HealthCareClaims.asp#TopOfPage

•Support for filing paper claims at: www.cms.hhs.gov/ElectronicBillingEDITrans/16_1500.asp#TopOfPage

MEDICARE ELECTRONIC PAYMENTS

•ABN (paper form CMS-R-131) can be used for cases

where Medicare payment expected to be denied

•Notifies beneficiary prior to service that:

– Medicare will probably deny payment for service

– Reason why Medicare may deny payment

– Beneficiary will be responsible for payment if Medicare denies payment

ADVANCE BENEFICIARY NOTICE (ABN)

ADVANCE BENEFICIARY NOTICE (ABN)

•NOT required for benefits statutorily excluded by

Medicare (e.g. MNT for HTN).

•BUT, can also used:

– When unsure service is medically necessary, or

– Service may exceed frequency or duration limit

– In place of Notice of Exclusion from Medicare

Benefits to inform beneficiary that service is not

covered by Medicare

•GA: Service expected to be denied as not reasonable or necessary. Waiver of liability (ABN) on file.

•GZ: Service expected to be denied as not reasonable or necessary. Waiver of liability NOT NOT on file.

• If provider knows that MNT--DSMT claim will be denied, pt or provider can submit denied claim

to supplemental insurance

– Some private payers may require Medicare denial first before considering to pay

• GY modifier added to code to obtain denial

MODIFIERS for PROCEDURE CODES

PRIVATE PAYER and MEDICAID COVERAGE of MNT--DSMT

•Coverage policies and, if paid, coverage rules, do vary:

– From state to state among major plans (BCBS of IL. vs. BCBS of CA.)

– Among plans in payer company (HMO vs. PPO)

– Among state Medicaid plans

•Some cover pre-diabetes (glucose intolerance, IFG)

RULES OF THUMBCall each and every payer in local area (or check website) to inquire about payer’s MNT-DSMT:

1. Coverage policy

> Does payer cover services?

2. Coverage guidelines re:

> Referring provider

> Pt eligibility and entitlement

> Benefit structure, utilization limits, place of service

> Billing rules, esp. procedure codes

> Reimbursement rates

•47 states have insurance laws that require private payer coverage for:

– DSMT– Diabetes-related services and supplies1

•Laws supersede any coverage limitations in health plan

•Exclusions do exist (e.g., state/federal employer health plans often exempt from state mandates)

1. www.ncsl.org/programs/health/diabetes.htm (National Conference of State

Legislatures) Accessed 3-26-12

STATE INSURANCE MANDATES for PRIVATE PAYERS

PROCEDURE CODES for

MNT--DSMT

NOT NOT PAID by MEDICARE

BUT MAY be REQUIRED by

PRIVATE PAYERS and MEDICAID

S9140 Diabetes management program, f/up visit to non-MD provider

S9141 Diabetes management program, f/up visit to MD provider

S9145 Insulin pump initiation, instruction in initial use of pump (pump not included)

S9455 Diabetic management program, group session

S9460 Diabetic management program, nurse visit

S9465 Diabetic management program, dietitian visit

S9470 Nutritional counseling, dietitian visit

98960 Individual, initial or f/up face-to-face education, training & self-management, by qualified non-physician HCP using standardized curriculum (may include family/caregiver), each 30 min.

98961 Group of 2 - 4 pts, initial or f/up, , each 30 min.

98962 Group, 5 - 8 pts, initial or f/up, , each 30 min.

Do NOT require DSMT program accreditation.

98960, 98961, 98962:

• For pts with established illnesses/diseases or to delay co-morbidities

• Physician/NPP must Rx education and training

• Non-physician's qualifications and program's contents must be consistent with guidelines or standards established or recognized by physician society, non-physician HCP society/association, or other appropriate source

WE GOT RID OF THE KIDS…..WE GOT RID OF THE KIDS…..THE CAT WAS ALLERGICTHE CAT WAS ALLERGIC

•Consultation codes:– 99241-99245, 992510–99255

•Medical Team Conference codes:– 99366 and 99368

•Telephone Services codes:– 99441 – 99443: non face-to-face services

•On-Line Medical Evaluation– 99444: Internet/electronic communications

network; not related to evaluation & management (E&M) visit within last 7 days

PROCEDURE CODES NOTNOT PAID by MEDICARE

I’m I’m sleepy

sleepy after after all that

all that info!info!

INCREASE REIMBURSEMENT NOW!INCREASE REIMBURSEMENT NOW!

ALL IT TAKES IS A LITTLE DESIRE AND STRENGTH ON YOUR PART!

YOUR PATIENTS, PROVIDERS & STAFF

WILL LOVELOVE YOU FOR IT!

DO YOUR HOMEWORK, BE PREPARED AND TAKE THE PLUNGE!

OTHERWISE, YOU’RE GOING TO WAKE UP ONE MORNING, AND REALIZE YOU’VE

MADE A SIGNIFICANT BOO-BOO!

EFFECT OF INFORMATION EFFECT OF INFORMATION OVERLOADOVERLOAD

MARY ANN WILL NOW MARY ANN WILL NOW

ENTERTAIN YOUR QUESTIONSENTERTAIN YOUR QUESTIONS

This information is intended for educational and reference This information is intended for educational and reference purposes only. It does not constitute legal, financial, medical or purposes only. It does not constitute legal, financial, medical or other professional advice. other professional advice. The information does not necessarily reflect opinions, policies The information does not necessarily reflect opinions, policies and/or official positions of the Center for Medicare and Medicaid and/or official positions of the Center for Medicare and Medicaid Services, private healthcare insurance companies, or other Services, private healthcare insurance companies, or other professional associations. Information contained herein is subject professional associations. Information contained herein is subject to change by these and other organizations at any moment, and is to change by these and other organizations at any moment, and is subject to interpretation by its legal representatives, end users and subject to interpretation by its legal representatives, end users and recipients. Readers should seek professional counsel for legal, recipients. Readers should seek professional counsel for legal, ethical and business concerns. The information is not a ethical and business concerns. The information is not a replacement for the Academy of Nutrition and Dietetics’ Nutrition replacement for the Academy of Nutrition and Dietetics’ Nutrition Practice Guidelines or American Diabetes Association’s Practice Guidelines or American Diabetes Association’s Standards of Medical Care in Diabetes. As always, the reader’s Standards of Medical Care in Diabetes. As always, the reader’s clinical judgment and expertise must be applied to any and all clinical judgment and expertise must be applied to any and all information in this document.information in this document.

Mary Ann Hodorowicz Consulting, LLCMary Ann Hodorowicz Consulting, LLC hodorowicz@comcasthodorowicz@comcast

708-359-3864708-359-3864 www.maryannhodorowicz.com www.maryannhodorowicz.com

• Turn Key Materials for AADE DSME Program AccreditationTurn Key Materials for AADE DSME Program Accreditation DSME Program Policy & Procedure Manual Consistent with NSDSME (69 pages)DSME Program Policy & Procedure Manual Consistent with NSDSME (69 pages)

Medicare, Medicaid and Private Payer ReimbursementMedicare, Medicaid and Private Payer Reimbursement Electronic and Copy-Ready/Modifiable Forms & HandoutsElectronic and Copy-Ready/Modifiable Forms & Handouts Fun 3D Teaching Aids for AADE7 Self-Care TopicsFun 3D Teaching Aids for AADE7 Self-Care Topics Complete Business PlanComplete Business Plan

• 3-D DSME/T Teaching Aids ‘How-To’ Kit3-D DSME/T Teaching Aids ‘How-To’ Kit• Kit of 20 monographs describing how to make Mary Ann’s 20 separate 3-D Kit of 20 monographs describing how to make Mary Ann’s 20 separate 3-D teaching aids plus fun teaching points, evidence-based guidelines and referencesteaching aids plus fun teaching points, evidence-based guidelines and references

• Money Matters in MNT and DSMT: Increasing Reimbursement Success Money Matters in MNT and DSMT: Increasing Reimbursement Success in All Practice Settings, The Complete Guide ©”, 5th. Edition, 2012in All Practice Settings, The Complete Guide ©”, 5th. Edition, 2012

• Establishing a Successful MNT Clinic in Any Practice Setting ©”Establishing a Successful MNT Clinic in Any Practice Setting ©”

• EZ Forms for the Busy RD” ©: 107 total, on CD-r; Modifiable; MS WordEZ Forms for the Busy RD” ©: 107 total, on CD-r; Modifiable; MS Word Package A: Diabetes and Hyperlipidemia MNT Intervention Forms, 18 FormsPackage A: Diabetes and Hyperlipidemia MNT Intervention Forms, 18 Forms Package B: Diabetes and Hyperlipidemia MNT Chart Audit Worksheets: 5 FormsPackage B: Diabetes and Hyperlipidemia MNT Chart Audit Worksheets: 5 Forms Package C: MNT Surveys, Referrals, Flyer, Screening, Intake, Analysis and Package C: MNT Surveys, Referrals, Flyer, Screening, Intake, Analysis and

Other Business/Office and Record Keeping Forms: 84 FormsOther Business/Office and Record Keeping Forms: 84 Forms