Private Practice: Private Practice: Understanding Forms, Understanding Forms, Codes, and Insurances! Codes, and Insurances!
Amy Cartwright, MS, RD, LDNAmy Cartwright, MS, RD, LDNPrivate Practice DietitianPrivate Practice Dietitian
GOALSGOALS This session will help you to:This session will help you to:
– Understand the steps involved in Understand the steps involved in becoming a credentialed provider becoming a credentialed provider with insurance companieswith insurance companies
– Learn codes that RD’s can use to Learn codes that RD’s can use to be reimbursed for their services be reimbursed for their services
– Properly fill out an insurance claim Properly fill out an insurance claim and appeal denials. and appeal denials.
Where to startWhere 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 Determine whether or not you want to accept insurances in your private practiceaccept insurances in your private practice
Identify which insurance companies are popular in your area.
Next StepNext Step National Provider Identifier (NPI)National Provider Identifier (NPI)
– A number that uniquely identifies A number that uniquely identifies health care providershealth care providers
– Apply at 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
Next StepNext Step Credentialing with Insurance CompaniesCredentialing with Insurance Companies
– Contact local insurance companies to Contact local insurance companies to determine if they credential Registered determine if they credential Registered DietitiansDietitians
– Credentialing can take up to 2 monthsCredentialing can take up to 2 months– Determine if you want to be a Medicare Part Determine if you want to be a Medicare Part
B provider or “Opt Out”B provider or “Opt Out”– Successfully credentialed with First Priority Successfully credentialed with First Priority
Health/Life, Aetna, Federal Employees Health/Life, Aetna, Federal Employees ProgramProgram
Insurance CompaniesInsurance Companies– Each insurance company has their own Each insurance company has their own
guidelines as to what they cover and guidelines as to what they cover and how much will be reimbursed.how much will be reimbursed.
– Example: One policy may allow for 24 Example: One policy may allow for 24 units to be covered per calendar year (a units to be covered per calendar year (a unit is 15 min) while others only allow 2-unit is 15 min) while others only allow 2-3 visits per year.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- CAQH https://upd.caqh.org/oas/https://upd.caqh.org/oas/ An online service intended to eliminate
the need for multiple insurance credentialing submissions
Benefits:– Saves time!Saves time!– Reduces paperworkReduces paperwork– Keeps your information currentKeeps your information current– And it’s FREE!And it’s FREE!
Codes and CoverageCodes and Coverage RD’s have fought for many years to have RD’s have fought for many years to have
reimbursable servicesreimbursable services The effort continues- as we break through The effort continues- as we break through
one glass ceiling another one seems to one glass ceiling another one seems to appear!appear!
January 2002- Medicare started January 2002- Medicare started reimbursement for DM and Renal Diseasereimbursement 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 CoverageCodes 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 CodesDiagnostic 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 CodesICD 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 DiseaseChronic 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 CodesAdditional 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 unit15 minutes= 1 unit– Must bill/charge the insurance company the Must bill/charge the insurance company the
same fee for all clients that receive the same fee for all clients that receive the same servicesame service
– Insurance companies have their own fee Insurance companies have their own fee schedule which can be found in your signed schedule which can be found in your signed agreement with them and can be agreement with them and can be negotiatednegotiated
Filing Insurance ClaimsFiling 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 Electronic filing uses the CMS 1500 as a template for all claims
Electronic Filing websitesElectronic Filing websites– http://www.officeally.com/http://www.officeally.com/– http://www.navinet.net/http://www.navinet.net/
Reasons for DenialsReasons for Denials Error on claimError on claim
– Make sure all required boxes are filled inMake sure all required boxes are filled in No coverageNo coverage
– Verifying benefits prior to visits is Verifying benefits prior to visits is importantimportant
No referralNo referral– Must get referral from physician with a Must get referral from physician with a
dxdx
Denials- ExampleDenials- 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 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 contDenials cont Consult with other registered
dietitians in the immediate area to see if they have faced this same problem and what outcome was reached
ResourcesResources www.eatright.org/mntwww.eatright.org/mnt NE Nutrition Entrepreneurs DPG NE Nutrition Entrepreneurs DPG
http://www.nedpg.org/http://www.nedpg.org/ https://nppes.cms.hhs.gov/NPPES/
Welcome.do https://upd.caqh.org/oas/https://upd.caqh.org/oas/
THANK YOU!THANK YOU!
