Private Practice: Understanding Forms, Codes, and Insurances!

1. Private Practice: Understanding Forms, Codes, and Insurances! Amy Cartwright, MS, RD, LDN Private Practice Dietitian

3. 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.

4. 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.

5. Next Step • National Provider Identifier (NPI) • A number that uniquely identifies health care providers • Apply at https://nppes.cms.hhs.gov/NPPES/Welcome.do • Can take up to 2 wks to receive # • This # is necessary to be credentialed with insurance companies

6. 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

7. 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.

8. 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!

9. 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

10. 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

11. 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

12. 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)

13. 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

14. 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

15. 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/

18. 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

19. 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.

20. 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.

21. 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

22. Resources • www.eatright.org/mnt • NE Nutrition Entrepreneurs DPG http://www.nedpg.org/ • https://nppes.cms.hhs.gov/NPPES/Welcome.do • https://upd.caqh.org/oas/

23. THANK YOU!