QIN-QIO Public Sharing Call:The Basics for Achieving Medicare Reimbursement for DSMT

Thursday, November 8, 20183:00-4:30 PM ET

Welcome and Reminders

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• Please be prepared for sharing and open discussion

• Slides and a recording from today’s session can be found on: https://qioprogram.org/qin-qio-public-sharing-calls-3-part-series

Lindsay KaatzEvent Lead

Susan BrittmanChat Manager

Purpose

• Audience: Community and healthcare providers, local partners, federal partners, and Quality Improvement Organization (QIO) Program partners (*registration required)

• Purpose: The purpose of this session is to review the Medicare reimbursement rules for the DSMT benefit and the current payment rates.

• Expectations: Participants will gain knowledge that is directly applicable to their work in healthcare quality improvement and acquire information that can be easily shared among their own community, organization, or team

• Topics: Topics will be aligned with the CMS Quality Strategy goals

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Audience Poll

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Please indicate your profession:• Physician• Registered nurse or nurse practitioner• Pharmacist or pharmacy technician• Dietician• Quality improvement professional• Healthcare administrator• Other (please specify in chat)

Learning Objectives

• Describe the beneficiary eligibility criteria for Medicare DSMT.

• State the 3 lab tests for diagnosing T1 and T2 diabetes, one of which Medicare requires for DSMT beneficiary eligibility.

• List the 3 conditions for reimbursement of 10 initial DSMT hours as individual visits.

• Describe 3 of the key and unique Medicare coverage guidelines for DSMT telehealth.

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Things to Think About

Will you commit to being… • Attentive• Active• Actionable

Show your commitment by clicking the green checkmark!

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Continuing Education Credit

Continuing education credit is available for:• Physicians and Physician Assistants• Registered Nurses and Nurse Practitioners• Dietitians• Pharmacists and Pharmacy Technicians• Certificate of Attendance

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Method of Participation & Instructions for Claiming CE

• Attend the entire event• Complete the post-event assessment that will pop up at

the conclusion of the event• There is a separate evaluation required for CE linked

within the post-event assessment• Once you submit your CE evaluation, you will be

provided with a certificate to retain for your records• For technical assistance, please email Nikki Racelis

(nikki.racelis@qinncc.hcqis.org)• If you have questions about this CME/CE activity, please

contact AKH Inc. at service@akhcme.com.

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CE Information

Physicians:This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AKH Inc., Advancing Knowledge in Healthcare, CRW & Associates and Telligen. AKH Inc., Advancing Knowledge in Healthcare is accredited by the ACCME to provide continuing medical education for physicians.

AKH Inc., Advancing Knowledge in Healthcare designates this live activity for a maximum of 1.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Physician Assistants:NCCPA accepts AMA PRA Category 1 Credit™ from organizations accredited by ACCME.

Pharmacists:AKH Inc., Advancing Knowledge in Healthcare is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.AKH Inc., Advancing Knowledge in Healthcare approves this knowledge-based activity for 1.5 contact hours (0.15 CEUs). UAN 0077-9999-18-046-L04-P; UAN 0077-9999-18-046-L04-T. Initial Release Date: 11/8/2018

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CE Information, Continued

Registered Nurses:AKH Inc., Advancing Knowledge in Healthcare is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.This activity is awarded 1.5 contact hours.

Nurse Practitioners:This activity has been planned and implemented in accordance with the accreditation Standards of the American Association of Nurse

Practitioners (AANP) through the joint providership of AKH Inc., Advancing Knowledge in Healthcare, CRW & Associates and Telligen. AKH Inc., Advancing Knowledge in Healthcare is accredited by the American Association of Nurse Practitioners as an approved provider of nurse practitioner continuing education. Provider number: 030803This activity is accredited for 1.5 contact hour(s) which includes 0 hour(s) of pharmacology. Activity ID #218195

Dietitians:AKH Inc., Advancing Knowledge in Healthcare is a Continuing Professional Education (CPE) Accredited Provider with the Commission on Dietetic Registration (CDR). Registered dietitians (RDs) and dietetic technicians, registered (DTRs) will receive 1.5 continuing professional education units (CPEUs) for completion of this program/material. CDR Accredited Provider #AN008. The focus of this activity is rated Level 2. Learners may submit evaluations of program/materials quality to the CDR at www.cdrnet.org.

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Disclosure of Financial Relationships & Commercial Support

• The planners and faculty do not have any relevant financial relationships to disclose.

• AKH Inc., CRW & Associates, and Telligen do not have any relevant financial relationships to disclose.

• No commercial support was received for this activity.

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Disclosure of Financial Relationships & Commercial Support

Disclosures:It is the policy of AKH Inc. to ensure independence, balance, objectivity, scientific rigor, and integrity in all of its continuing education activities. The author must disclose to the participants any significant relationships with commercial interests whoseproducts or devices may be mentioned in the activity or with the commercial supporter of this continuing education activity. Identified conflicts of interest are resolved by AKH prior to accreditation of the activity and may include any of or combination of the following: attestation to non-commercial content; notification of independent and certified CME/CE expectations; referral toNational Author Initiative training; restriction of topic area or content; restriction to discussion of science only; amendment of content to eliminate discussion of device or technique; use of other author for discussion of recommendations; independent review against criteria ensuring evidence support recommendation; moderator review; and peer review.

Disclosure of Unlabeled Use and Investigational Product:This educational activity may include discussion of uses of agents that are investigational and/or unapproved by the FDA. Pleaserefer to the official prescribing information for each product for discussion of approved indications, contraindications, andwarnings.

Disclaimer:This course is designed solely to provide the healthcare professional with information to assist in his/her practice and professional development and is not to be considered a diagnostic tool to replace professional advice or treatment. The course serves as ageneral guide to the healthcare professional, and therefore, cannot be considered as giving legal, nursing, medical, or otherprofessional advice in specific cases. AKH Inc. specifically disclaim responsibility for any adverse consequences resulting directly or indirectly from information in the course, for undetected error, or through participant's misunderstanding of the content.

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Meet Your Speaker

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Mary Ann HodorowiczRDN, MBA, CDE, CEC

Mary Ann Hodorowicz Consulting, LLC

Money Matters in DSMT:Increase Your Insurance

Reimbursement NOW!

Mary Ann Hodorowicz, RDN, MBA, CDECertified Endocrinology Coder

Mary Ann Hodorowicz Consulting, LLC (10-11-18; Appendix)

Mary Ann Hodorowicz, RDN, MBA, CDE, CEC, is a licensed registered dietitian and certified diabetes educator and earned her MBA with a focus on marketing. She is also a certified endocrinology coder and owns a private practice specializing in corporate clients in Palos Heights, IL. She is a consultant, professional speaker, trainer, and author for the health, food, and pharmaceutical industries in nutrition, wellness, diabetes, and Medicare and private insurance reimbursement. Her clients include healthcare entities, professional membership associations, pharmacies, medical CEU education & training firms, government agencies, food and pharmaceutical companies, academia, and employer groups. She served on the Board of Directors of the American Association of Diabetes Educators from 2013 – 2015, and was the Chair of the Advanced Practice Community of Interest in 2016.

Mary Ann Hodorowicz Consulting, LLC hodorowicz@comcast.net 708-359-3864

www.maryannhodorowicz.com Twitter: @mahodorowicz

Mary Ann Hodorowicz

RDN, MBA, CDE,

CEC

(Certified

Endocrinology

Coder)

LEARNING OBJECTIVES1. Describe the beneficiary eligibility criteria for Medicare DSMT.

2. State the specific lab values of the 3 lab tests that diagnose T1 and T2 diabetes.

3. Name the procedure codes used to bill Medicare for DSMT.

4. Describe the quality standards for Medicare DSMT.

5. Name the approved referring providers for Medicare DSMT.

6. Describe the 3 conditions for which all 10 initial DSMT hours can be furnished individually.

7. Describe 3 of the key and unique Medicare coverage guidelines for DSMT

THE GOLDEN RULE• He who has the gold makes the rules!

• He who wants the gold must identify all the rules…and follow

all rules.

• He who doesn’t follow the rules will likely have to give all the

gold back…..and pay penalties and fines.

• He who has to give all the gold back…along with penalties and

fines…will likely be out of a job!

INSURER’S RULES RULE!

MEDICARE DSMT REIMBURSEMENT RULES:COPIOUS, CONVOLUTED, CONFUSING, COMPLICATED, and

CONSTANTLY CHANGING!

MEDICARE BENEFICIARY DSMT ENTITLEMENT

Must have Medicare Part B insuranceSuggestion: scan/make copy of Medicare card for MR

MEDICARE MNT and DSMT: COMPLIMENTARY but DISTINCT

MNT• Personalized nutrition (and

related) therapy to control A-B-C’s of diabetes, primarily as individual visits

• Personalized behavior change plans* primarily for eating. Adjustments in SMBG, exercise & medication plans suggested, as required by eating plan

• Long-term follow-up with extensive monitoring of labs, outcomes, behavior change, with adjustments in plans*

DSMT• General, one-size-fits all training on AADE7™ self-care behaviors to control A-B-C’s of diabetes, primarily in group format

• Objective is to increase patients’ knowledge of why and basic skill in how to: adopt healthier lifestyle behaviors; adhere to their medication and SMBG regimen

• Shorter-term follow-up with morelimited monitoring of labs, outcomes, behavior change, etc. over time

COORDINATION OF MEDICARE MNT--DSMT

Medicare covers MNT and DSMT...but NOT on same day!

Initial MNT: 3 Hours* in Calendar Year

T1, T2 diabetes; GDM; non-dialysis renaldisease; 36 months after kidney transplant.

RDN adheres to 4 Step Nutrition Care Process and

Evidence-based nutrition practice guidelines.

*3 hours can be individual and/or group.Special condition not required for individual.

Initial DSMT: 10 Hours* in 12 Consecutive MonthsT1, T2 diabetes; GDM.

Must have AADE accreditation or ADA recognition.Must adhere to 2017 National Standards of DSMES.

Nutrition is 1 of 10 topics taught as overview ofhealthy eating to control A-B-C's of diabetes.

No individualized eating plans (this is MNT).

*9 hours of 10 must be in GROUP.**10 hours can be INDIVIDUAL but ONLY if

1 of 3 special conditions documented.**2 or more pts; need not be all Medicare.

DSMT: HOW 10 INITIAL HOURS TO BE FURNISHED

1 hour of 10 may be INDIVIDUAL on any topic.9 hours of 10 to be furnished in GROUP.

BUT: All 10 hours can be INDIVIDUAL if 1 of 3 conditions exist:

1. No group class scheduled within 2 months of referral date.2. Provider orders "additional insulin training" on DSMT referral.

3. Provider documents on referral a beneficary need that limits group learning.

Examples of special needs:Hearing; vision; language; cognitive; non-ambulatory.

MEDICARE DSMT BILLING PROVIDER ELIGIBILITY

Select individual and entity providers can bill. Must be billing for other Medicare services first.

Cannot join Medicare just to bill for DSMT.

Individual providers who can bill for all DSMTfurnished, if part of program: physician; RD;nutrition professional; NP; PA; CNS; certified

nurse midwife; CLSW, clinical licensed psychologist.

Entities paid via Physician Fee Schedule:hospital OP dept.; clinic; practice of RD,

physician, NP, PA, CNS; home health agency;pharmacy; skilled nursing facility; DME

Entities paid via payment models:FQHC (fixed + bundled); rural health clinic (cost).

No payment allowed in: hospice care;nursing home; inpt hospital; ESRD facility.

My mothertaught meabout the science ofOsmosis…

“Shut yourmouth andeat your supper!”

MEDICARE DSMT QUALITY STANDARDS

Program certification required (ADA recognitionor AADE acreditation). Send copy of certificate

to Medicare Administrative Contractor (MAC), return receipt.

Both require adherence to 2017National Standards of DSMES. Standard 5:

RD, RN or pharmacist on team; can be solo instructor;but multi-disciplinary team recommended.

Rural Health Clinic:If solo instructor, must be RD-CDE.

CMS defines rural area (www.cms.gov)

MEDICARE DSMT LITTLE KNOWN RULES + ADVICE

Diabetes can be dx'd prior to Part B entry.Beneficiary on renal dialysis only eligible for non-nutrition DSMT.

Initial DSMT: continuous 12 month period starts with date of 1st visit.

Initial not received ever before (once in lifetime benefit).Once started, must be completed/billed

within 12 consecutive months from date of 1st visit.

Beneficiaries in group or 1:1 visit to sign attendance sheet.

3 ways to determine if beneficary had any initial DSMT in past:--Ask beneficiary to call 1-800-MEDICARE and ask--Call your Medicare Administrative Contractor and ask--Access portal of beneficiary transactions on your Medicare Administrative Contractor website

MEDICARE DIAGNOSTIC LAB ELIGIBILITY for DSMT

Documentation of T1 or T2 diabetes diagnosisusing 1 of 3 lab tests:

1) Fasting plasma glucose x 2 tests2) Two hour OGTT x 2 tests3) Random BG x 1 test with high BG symptom(s)

MEDICARE DIAGNOSTIC LAB ELIGIBILITY for DSMT

FPG >/= 126 mg on 2 tests, or2 hr OGTT >/= 200 mg on 2 tests, or

Random BG >/=200 mg + uncontrolled DM symptom*.A1c not added as of 5-24-18^

Gestational DiabetesProvider to provide documentation of

gestational diabetes dx code.

*Symptoms of uncontrolled diabetes:Excessive thirst, hunger, urination, fatigue,

blurred vision; unintentional wt loss; tingling, numbnessin extremities; non-healing cuts/wound, etc.

^A1c >/= 6.5% is diagnostic for T1, T2 DMper ADbA, Standards of Medical Care, 2018

*Federal Register, Vol. 68, #216, 11-7-03, p.63261

WHO MUST HAVE DOCUMENTATION OF MEDICARE DIAGNOSTIC LAB ELIGIBILITY for DSMT

First, remember who is allowed to order DSMT:

Treating* MDs, DOs and

qualified non-physician practitioners (NP, PA, CNS) can Rx.

*Treating means provider who is treating(i.e., medically managing) beneficiary's diabetes....

not just eyes, feet, kidneys, etc.

WHO MUST HAVE DOCUMENTATION OF MEDICARE DIAGNOSTIC LAB ELIGIBILITY for DSMT

DSMT benefit states physician or qualified non-physician practitioner treatingthe pt must document in medical record that "patient is a diabetic".

Best Practice Suggestion: Ask your practice'sMedicare Compliance Officer and/or your regional

Medicare Administrative Contractor (MAC) if YOU need copy of labs.

MEDICARE DSMT REFERRAL REQUIREMENTS

Written or e-referral by treating physician (MD, DO) orqualified non-physician practitioner (NPP): NP, PA,CNS.

For initial DSMT*: whether group or individual.

If individual: documentation on referral of special needs/conditionsthat warrants individual.

Physician (MD, DO) or NPP to maintain beneficiary's plan of care inchart maintained in his/her office.

*For follow-up DSMT:can be group or individual.

Special needs/conditions NOT required for individual follow-up DSMT.

MEDICARE DSMT REFERRAL REQUIREMENTS, CONT.

Rx date + beneficiary's name.

Narrative dx or ICD-10 code.Medicare prefers 5 character codes (highest degree of specificity).

See more slides for additional info on valid and invalid ICD-10 codesfor DSMT published by CMS.

Signature + NPI # of treating physician (MD, DO) or NPP.Stamped signature not allowed.E-signature in EMR is allowed.

Separate Rx required for: initial and follow-up DSMT.

For initial DSMT:-- Which of 10 topics to be taught.

-- How many hours of 10 to be taught.

SNIPPET of MARY ANN’S MEDICARE DSMT, MNT and IBT for OBESITY REFERRAL FORM

SNIPPET of MARY ANN’S MEDICARE DSMT, MNT and IBT for OBESITY REFERRAL FORM

SNIPPET of MARY ANN’S MEDICARE DSMT, MNT and IBT for OBESITY REFERRAL FORM

Revised August

2011

Can download on websites of:

American Association of

Diabetes Educators

Academy of Nutrition and

Dietetics

MEDICARE DSMT FREQUENCY in FIRST YEAR and STRUCTURE OF

Enter code one time +number of units of G code furnished on claim .

Visits are >/= 30 min. (1 billing unit; no rounding).Document start + end. time to prove that whole30 min. unit(s) of face-to-face time furnished.

9 hrs must be in group (G0109) unless1 of 3condiitions exist.

10 hours may be used for only 1 topic (new!).

10 hrs in 12 consecutive months.Cannot extend into next year.

1 hr individual (G0108) may be be used for insulintraining, any topic or assessment.

Medicare will not pay for MNT and DSMT provided on same day!

MEDICARE DSMT FREQUENCY in FIRST YEAR + STRUCTURE OF

ALL 10 hours can be individual IF 1 of 3 conditions exist:1. Referring provider documents pt's special need

that limits group learning* on Rx

2. Referring provider orders additional insulin training on RX.3. No group class scheduled within 2 months of Rx date.

*Examples: vision, hearing, cognitive, language, non-ambulatory.

NEW! MEDICARE DSMT MEDICAL UNLIKELY EDITS (MUEs) EFFECTIVE 7/1/15

aka: Limits on number of units of code payable per visit

HCPCSCode

OP HospitalServices MUE Values

Practitioner ServicesMUE Values

G0108

IndividDSMT

8 units= 4 hours

6 units = 3 hours

G0109

GroupDSMT

12 units= 6 hours

12 units= 6 hours

MEDICARE DSMT FREQUENCY in FOLLOW-UP YEARS + STRUCTURE

Special needs do NOT need to be documentedfor individual follow-up DSMT.

.Can obtain follow-up even if INITIAL DSMT was not received.

Individual or group visit: >/= 30 min = 1 billing unitNo rounding allowed.

New Rx required for follow-up DSMT..

Follow-Up DSMT After First 12 Consecutive Months

2 hours each 12 months after initial DSMT completed.Cannot extend hours into next 12 months.Individual, group or combination allowed.

Special conditions not required for individual f/up.

DOCUMENT “START’ TIME and ‘END’ TIME FOR EVERY VISIT!

MEDICARE TIME FRAMES for FOLLOW-UP DSMT: EXAMPLE

Completes Initial 10 Hours Spanning 2 Years: 2017 , 2018:• Starts initial 10 hours in August 2017• Completes initial 10 hours in August 2018• Eligible for…and starts…2 hour follow-up in September, 2018• Completes 2 hour follow-up in Dec., 2018• Eligible for next 2 hour follow-up in Jan., 2019

Completes Initial 10 Hours in Same Calendar Year: • Starts initial 10 hours in August 2018• Completes initial 10 hours in Dec., 2018• Eligible for…and starts…2 hours follow-up in Jan., 2019• Completes 2 hour follow-up in July 2019• Eligible for next 2 hour follow-up in Jan. 2020

PROCEDURE CODES REQUIRED by MEDICARE and COMMONLY ACCEPTED by PRIVATE PAYERS

Visit can be any number of units but must be >1 1 Unit

97802 MNT, initial episode of care (EOC), individualUsed ONLY 1 time for very first initial visit!

15 min

97803 MNT, follow-up EOC, individual 15 min

97804 MNT, initial or follow-up EOC, group 30 min

G0270 MNT, initial, individual, >3 hours or follow-up, individual, >2 hours per 2nd referral, same year

15 min

G0271 MNT, initial, group, >3 hours or f/up, group, >2 hours per 2nd referral, same year

30 min

G0108 DSMT, individual, initial or follow-up, 30 min. 30 min

G0109 DSMT, group, initial or follow-up, 30 min. 30 min

MEDICARE DSMT 2018 NATIONAL UNADJUSTED REIMBURSEMENT RATES (www.cms.gov)

MNT National Unadjusted* Rates DSMT National Unadjusted* RatesBased on Medicare Physician Fee Schedule Based on Medicare Physician Fee Schedule

Rate: 85% of MPFS. Rate: 100% of condensed MPFS for par providers,20% beneficiary copay waived but paid by Medicare. but only 95% for non-par providers.

Medicare pays 80% of adjusted rate; beneficiary, 20%.

97802: Individual, initial, 15 min. G0108: Individual, initial or follow-up, 30 min.Facility: $33.12; Non-facility: $35.28 Facility and non-facility: $54.36

97803: Individual, follow-up, 15 min. G0109: Group, initial or follow-up, 30 min.Facility: $28.08; Non-facility: $30.60 Facility and non-facility: $14.76

97804: Group, initial or follow-up, 30 min. *Rates are geographically adjusted for region.Facility: $15.48; Non-facility: $16.20 Facility = hospital.

My mother taught

me about

contortionism:

Will you look

at the dirt on

the back of

your neck!

OFF-SITE LOCATIONS FOR MEDICARE DSMT

HOSPITAL OUTPATIENT DSMT RULE

OP DSMT services must be furnished in:- In the hospital

OR--In a provider-based hospital department

DSMT not payable IF furnished at alternatenon-hospital, off-site locations.

Non-Hospital Entities that Submit Professional 1500 Claims:Physician practices, RDN practices, clinics, pharmacies.

Can be "parent" or "primary" sites of DSMT program.

May furnish DSMT at these "parent" sites and bill Medicare Part B.May also furnish at "off-site" locations, even if NOT owned by parent site.

Non-Medicare Note: AADE accredited BRANCH DSME sites must beunder same corporate umbrella as "parent" or "primary" site.

AADE accredited COMMUNITY sites do not have to meet this requirement.

OFF-SITE LOCATIONS FOR MEDICARE DSMT, CONT.

.

HOME HEALTH AGENCY and ESRD FACILITY MEDICARE DSMTBILLING

Home Health Agency End Stage Renal Dialysis Facility

DSMT DSMTYES separate Part B bill NO separate Part B billwhen outside of Part A

treatment plan on 34x bill

DSMTPart A home health benefitand Part B DSMT can be

received at same time

.

SKILLED NURSING FACILITY and NURSING HOME MEDICARE DSMT BILLING

Skilled Nursing Facility Nursing Home

DSMT DSMTYES, payable by Part B. NOT payable.

BOTE: Part A SNF benefit andPart B DSMT can be received at same time

Use 22x, 23x type of billRevenue code 0942

FEDERALLY QUALIFIED HEALTH CENTER

and

RURAL HEALTH CLINIC

DSMT BILLING

DEFINITION OF OUTPATIENT PROSPECTIVE PAYMENT SYSTEM

Only INDIVIDUAL DSMTpayable under Medicare Part B.

FQHCs and RHCs method of reimbursement based onOP Prospective Payment System.

FQHC: Claim based.RHC: Cost based (costs on annual Medicare cost report).

Examples of classification of services:Inpatient hospital pt, FQHC pt, RHC pt, home patient.

Examples of services:DSMT, MNT, physician visit, mental health visit, etc.

Defining OP Prospective Payment System (PPS) Rate:Payment is predetermined, bundled and fixed

for classification of service(s) and services on same day to pt.

DEFINITION OF OUTPATIENT PROSPECTIVE PAYMENT SYSTEM

Rate NOT adjusted for individual patients.Provider always receive same payment

for providing same classification and type of service.

Info on PPS rate in FQHCs at:https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Index.html

FQHC MEDICARE DSMT BILLING, CONT.

Encounters with 1 HCP; and 2 multiple encounters with same HCPwhich take place on same day and at single location constitute a single visit.

Exception: when pt, subsequent to 1st. encounter, suffers illness/injuryrequiring additional diagnosis or treatment.

Include anything that helps adjudicate claim in remark field locator 80of the UB0�4 claim and in loop 2300 of the 837I.

Help me to always give 100% at work…

12% on Monday23% on Tuesday

40% on Wednesday20% on Thursday

5% on Fridays

FQHC MEDICARE DSMT BILLING, CONT.

Under Prospective Payment System:Individual DSMT not payable on same day as medical visit.

Why: DSMT considered medical visit...and 2 medical visits not payable on same day.

BUT: DSMT is payable on same day as behavioral health/mental visit.DSMT visit can be billed separately (2 visits can both be billed).

FQHC MEDICARE DSMT BILLING, CONT.

Medicare pays the FQHC the lesser of its total actual charges OR fixed PPS rate

for bundle of ALL services in qualifying visit* furnished to beneficiary on SAME day.

*Qualifying visit code entered on claim. Code determines fixed PPS rate for ALL

services furnished to beneficiary on SAME day.

Procedure codes (e.g., G0108) also listed on claimand

actual charges for each sevrice.

FQHC MEDICARE DSMT BILLING, CONT.

Must enter "qualifying visit" code on claim:G0467 = FQHC visit, established pt.

G0466 = FQHC visit, new pt.

FQHC MEDICARE DSMT BILLING, CONT.

Must also enter revenue code on claim:0522 = Home visit by FQHC practitioner.0521 = Clinic visit by member to FQHC.

Use TOB 77x in locator field 4 on UB-04 claim form.

No Part B deductible applies to approved FQHC services.

FQHC MEDICARE DSMT BILLING, CONT.

Payment Calculation for DSMT Visit: ONLY Encounter This Day

2018 FQHC Prospective Payment System (PPS) Rate = $166.60

REVENU QUALIFYING DSMT DSMT PPS RATE E CODE VISIT PROCEDURE ACTUAL FOR

CODE CODE CHARGE QUALIFYING VISIT CODE

G0467G0467, G0108, $106.00 $166.60

0521 medical 60 minutes,visit, 2 units of code

established patient

Lesser value is actual charge of $106.00.CMS pays 80% of lesser, or of $106.00, which is $84.80

FQHC MEDICARE DSMT BILLING, CONT.

In FQHC: individual DSMT is core service billable to Part B.BUT:

Group DSMT is NOT separately billable to Part B.

My father taught me about time

travel:

If you

don’t watch

out, I’m

going to

knock you

into next

week!

RURAL HEALTH CLINIC MEDICARE DSMT BILLING

• RHCs paid on a COST basis for INDIVIDUAL DSMT

• Cost is entered on annual Medicare annual Cost Report

o Group DSMT not payable on Cost Report

• But RHC must report individual DSMT procedure code G0108 as an “additional service line” (Line 2) on TOB 71x for CMS tracking.

• Cost-based reimbursement is based on all-inclusive rate (AIR) for medically-necessary primary health services and qualified preventive health services furnished by an RHC practitioner

SUMMARY: RURAL HEALTH CLINIC MEDICARE DSMT BILLING

ONLY individual DSMT covered...but separate Part B payment not furnished

But COST is calculated under All-Inclusive Rate (AIR) system and addedto RHC's COST REPORT with appropriate individual DSMT procedure code G0108.

But must also report procedure code G0108 on as an "additional service line" (Line 2) on TOB 71x for CMS tracking.

AADE accreditation or ADA recognition for DSMT program is required.

RURAL HEALTH CLINIC MEDICARE DSMT BILLING

From CMS publication “MLN Matters® Number: MM6445 Revised, Rural Health Clinic (RHC) and Federally Qualified Health Clinic (FQHC)

Policy Clarifications for DSMT and MNT Services Coverage and Billing Updates:

Separate payment to RHCs for these practitioners and services continues to

be precluded. However, RHCs are permitted to become certified providers of

DSMT services and report the cost of such services on their cost report

for inclusion in the computation of their all-inclusive payment rates.

Note that the provision of these services by registered dietitians or nutritional

professionals might be considered incident to services in the RHC setting,

provided all applicable conditions are met. However, they do not constitute

an RHC visit, in and of themselves. All line items billed on TOB 71x with

HCPCS code G0108 or G0109 will be denied.

RURAL HEALTH CLINIC MEDICARE DSMT BILLING

Beneficiary copay + Part B deductible do apply.

Use revenue code 0521

IF solo DSMT instructor in RHC, must be RD-CDE

REFERENCES FOR INFORMATION ON FQHC and RHC MEDICARE DSMT BILLING

Main references used for DSMT billing in FQHCs and RHCs

Medicare Benefit Policy Manual, Chap. 13, RHC/FQHC Services, Rev. 12-09-16

Medicare Benefit Policy Manual, Chap. 9, RHCs/FQHCs, Rev 12-31-15

CHANGES IN BILLABLE ICD-

10 CODES FOR

MEDICARE DSMT AND MNT:

EFFECTIVE 2016, 2017, 2018

CHANGES IN BILLABLE ICD-10 CODES FOR DSMT EFFECTIVE 2016 and 2017

CMS’ CR9861 MADE ADJUSTMENTS TO CMS NATIONAL COVERAGE DETERMINATION (NCD) 40.1

FOR DSMT

• Invalid ICD-10 dx codes end-dated effective 9/30/16:

o E08.321, E08.329, E08.331, E08.339, E08.341, E08.349, E08.351, E08.359o E09.321, E09.329, E09.331, E09.339, E09.341, E09.349, E09.351, E09.359o E10.321, E10.329, E10.331, E10.339, E10.341, E10.349, E10.351, E10.359o E11.321, E11.329, E11.331, E11.339, E11.341, E11.349, E11.351, E11.359o E13.321, E13.329, E13.331, E13.339, E13.341, E13.349, E13.351, E13.359

CMS’ CR9861 MADE ADJUSTMENTS TO CMS NATIONAL COVERAGE DETERMINATION (NCD) 40.1 FOR DSMT

• DSMT: Added new 2017 ICD-10 dx codes effective 10/1/16:

oE08.3211, E08.3212, E08.3213, E08.3291, E08.3292, E08.3293, E08.3311, E08.3312, E08.3313, E08.3391, E08.3392, E08.3393, E08.3411, E08.3412, E08.3413, E08.3491, E08.3492, E08.3493, E08.3511, E08.3512, E08.3513, E08.3521, E08.3522, E08.3523, E08.3531, E08.3532, E08.3533, E08.3541, E08.3542, E08.3543, E08.3551, E08.3552, E08.3553, E08.3591, E08.3592, E08.3593, E08.37X1, E08.37X2, E08.37X3

CMS’ CR9861 MADE ADJUSTMENTS TO CMS NATIONAL COVERAGE DETERMINATION (NCD) 40.1 FOR DSMT

• DSMT: Added new 2017 ICD-10 dx codes effective 10/1/16:

oE09.3211, E09.3212, E09.3213, E09.3291, E09.3292, E09.3293, E09.3311, E09.3312, E09.3313, E09.3391, E09.3392, E09.3393, E09.3411, E09.3412, E09.3413, E09.3491, E09.3492, E09.3493, E09.3511, E09.3512, E09.3513, E09.3521, E09.3522, E09.3523, E09.3531, E09.3532, E09.3533, E09.3541, E09.3542, E09.3543, E09.3551, E09.3552, E09.3553, E09.3591, E09.3592, E09.3593, E09.37X1, E09.37X2, E09.37X3

CMS’ CR9861 MADE ADJUSTMENTS TO CMS NATIONAL COVERAGE DETERMINATION (NCD) 40.1 FOR DSMT

• DSMT: Added new 2017 ICD-10 dx codes effective 10/1/16:

oE10.3211, E10.3212, E10.3213, E10.3291, E10.3292, E10.3293, E10.3311, E10.3312, E10.3313, E10.3391, E10.3392, E10.3393, E10.3411, E10.3412, E10.3413, E10.3491, E10.3492, E10.3493, E10.3511, E10.3512, E10.3513, E10.3521, E10.3522, E10.3523, E10.3531, E10.3532, E10.3533, E10.3541, E10.3542, E10.3543, E10.3551, E10.3552, E10.3553, E10.3591, E10.3592, E10.3593, E10.37X1, E10.37X2, E10.37X3

CMS’ CR9861 MADE ADJUSTMENTS TO CMS NATIONAL COVERAGE DETERMINATION (NCD) 40.1 FOR DSMT

• DSMT: Added new 2017 ICD-10 dx codes effective 10/1/16:

oE11.3211, E11.3212, E11.3213, E11.3291, E11.3292, E11.3293, E11.3311, E11.3312, E11.3313, E11.3391, E11.3392, E11.3393, E11.3411, E11.3412, E11.3413, E11.3491, E11.3492, E11.3493, E11.3511, E11.3512, E11.3513, E11.3521, E11.3522, E11.3523, E11.3531, E11.3532, E11.3533, E11.3541, E11.3542, E11.3543, E11.3551, E11.3552, E11.3553, E11.3591, E11.3592, E11.3593, E11.37X1, E11.37X2, E11.37X3

oO24.415, O24.425, O24.435

oUnspecified codes deleted effective 1/1/17: O24.019 O24.119 O24.819

NATIONAL COVERAGE DETERMINATION (NCD40.1):DATE: JANUARY 18, 2018 CHANGE REQUEST: 10318

EFFECTIVE DATE: APRIL 1, 2018

Diabetes Self-Management Training (DSMT):

• Delete ketoacidosis-related ICD-10 dx:

o E08.10, E09.10, E10.10, E13.10

These patients are cared for in an inpatient setting and DSMT is conducted on an outpatient basis

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R2005OTN.pdf

APPENDIX:

Medicare Telehealth DSMT

MEDICARE DSMT TELEHEALH BILLING BASICS

DEFINITION OF:HIPAA-compliant, interactive audio and video

telecommunication permitting real time communication and visualization.

EXCLUDED:Telephone calls, faxes, email without audio and visualization.

Real time texts. Stored and delayed transmissions of images of beneficiary.

Source: www.cms.gov/transmittals/downloads/R140BP.pdf

REIMBURSEMENT: Same as for original face-to-face DSMT benefits.

INDIVIDUAL and GROUP DSMTCan be delivered via telehealth.

All original billing and coding reimbursement rules apply.

DSMT SPECIAL REQUIREMENTS OVER & ABOVE ORIGINAL:

>1 hour of 10 hours in initial year and >1 hour of 2 hours in follow-up years to be

furnished in-person for training on injectable meds (individual or group).

Beneficiary must be present and participate in telehealth visit.

ORIGINATING SITE vs. DISTANT SITE

Originating site: where beneficiary is during DSMT visit.

Distant site: where HCP is during DSMT visit.

STATE LICENSURE/CERTIFICATION REQUIREMENT FOR INDIVIDUAL RENDERING AND BILLING PROVIDER

Rendering and billing provider must be licensed or certified in

state where the provider furnishes telehealth DSMT

AND in state where beneficiary receives the DSMT.

INDIVIDUAL RENDERING PROVIDER: WHO IS ALLOWED TO FURNISH DSMT TELEHEALTH?

“……Medicare telehealth services, including individual DSMT

services furnished as a telehealth service, could only be

furnished by a licensed physician assistant (PA),

nurse practitioner (NP), clinical nurse specialist (CNS),

certified nurse-midwife (CNM), clinical psychologist,

clinical social worker, or registered dietitian or nutrition

professional.”

Source:190.3.6 – Payment for Diabetes Self-Management Training (DSMT) as a Telehealth Service (Rev. 3476, Issued: 03-11-16, Effective: 01-01-15, Effective: 04-11-16), Medicare Claims Processing Manual, Chapter 12 – Physicians and Non-physician Practitioners (Rev. 3678, 08-12-16)

APPROVED DISTANT SITE PRACTITIONERS OF MEDICARE DSMT TELEHEALTH

• Physicians (MDs, DOs)• Physician assistants (PAs)

• Nurse practitioners (NPs)

• Clinical nurse specialists (CNSs)

• Certified nurse midwives (CNMs)

• Clinical psychologists

• Clinical social workers (CSWs)

• Registered dietitians (RDs) and nutrition

professionals

EXCLUDED DISTANT* SITES: WHERE HCP IS DURING DSMT VISIT

• Independent renal dialysis facilities

• Pharmacies

• Beneficiary’s home

• Rural health clinics

• Federally qualified health centers

GT MODIFIER AND CRITICAL ACCESS HOSPITALS METHOD II DISTANT SITES

• Critical Access Hospitals Method II:

o As of Oct. 1, 2018, GT modifier is required on their institutional claims

o GT is “via interactive audio and video telecommunications system”

Source: Revisions to the Telehealth Billing Requirements for Distant Site Services, MLN Matters No.: MM10583 Revised

APPROVED ORIGINATING SITES: WHERE BENEFICIARY IS DURING DSMT VISIT

• Physician or qualified non-physician practitioner office

• Hospital

• Critical Access Hospital (CAH)

• Rural Health Clinic (RHC)

• Federally Qualified Health Center (FQHC)

• Hospital and CAH-based renal dialysis center

• Skilled nursing facility (SNF)

• Community mental health center

GEOGRAPHIC CRITERIA FOR ORIGINATING SITES

• Originating sites must be located in health professional shortage area

(HPSAs) located in rural census tracts of urban areas as determined by

Office of Rural Health Policy…OR

• County outside of metropolitan statistical area (MSA)

NOTE:

• Originating sites NOT approved for DSMT telehealth:

o Beneficiary’s home

o Independent renal dialysis facility

o Sites within a MSA or not within a HPSA

DISTANT SITE BILLING FOR DSMT TELEHEALTH VISIT

• Report Place of Service (POS) code 02 along with procedure code G0108 (individual

DSMT, per 30 min.) or G0109 (DSMT, group, 2 or more, per 30 min.)

o POS code 02 certifies that:

Beneficiary had or will have >1 hour of 10 hrs in initial year and >1 hr of 2 hrs

in follow-up years furnished in-person for training on injectable medications

Health services provided or received, through telecommunication technology

Beneficiary was present at an eligible originating site when telehealth service

was furnished

ORIGINATING SITE BILLING FACILITY FEE FOR DSMT TELEHEALTH VISIT

• To claim facility fee, originating site must bill HCPCS code Q3014, “telehealth originating site facility fee“ in addition to procedure code

• Type of service is "9” on claim form (“other items and services”)

• Place of service (POS) code is “02”: location where health services and health related services are provided or received, through telecommunication technology

• Originating site facility fee is a Part B payment

o Medicare pays it outside of current fee schedule or other payment methodologies

ORIGINATING SITES ELIGIBLE TO RECEIVE FACILITY FEE FOR DSMT TELEHEALTH VISIT

• 2018 Medicare facility fee:

o For HCPCS procedure code Q3014

(Telehealth originating site facility fee)

is 80% of the lesser of the actual charge, or $25.76

o Beneficiary is responsible for any unmet deductible amount

and Medicare coinsurance

EXTRA INFORMATION: ABOUT FACILITY FEE BILLING

Hospital OP Dept.: Fee payment is as described on previous slide and not under OP prospective payment system (OPPS). Part A is billed.

CAH: Fee payment is separate from cost-based reimbursement methodology and is 80% of originating site facility fee. Part A is billed.

Physicians’ and practitioners’ offices: Fee payment is lesser of 80% of actual charge or 80% of originating site facility fee, regardless of location. Part B contractor does not apply geographic practice cost index to fee; fee statutorily set; not subject to geographic payment adjustments authorized under Physician Fee Schedule. Part B is billed.

Renal dialysis center (or satellite) based in hospital or CAH:Fee covered in addition to any composite rate or MCP amount. Bills Part A and must use revenue code 78x..

EXTRA INFORMATION: ABOUT FACILITY FEE BILLING, CONTINUED

Skilled nursing facility (SNF): Fee outside SNF prospective payment system bundle and not subject to SNF consolidated billing; separately billable Part B payment. Bills Part A and must use revenue code 78x.

Community Mental Health Center (CMHC): Fee not partial hospital service; does not count towards number of services used to determine payment for partial hospitalization services. Fee not bundled in per diem payment for partial hospitalization; separately billable Part B payment. Bills Part A and must use revenue code 78x.

Independent and provider-based RHCs and FQHCs: Fee billed to Part A using RHC or FQHC bill type and billing number. Code Q3014 is only non-RHC/FQHCservice that is billed using clinic/center bill type and provider number. Must use revenue code 078x.

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

DSMT CLAIM FORMS for HOSPITALS and PRIVATE PRACTICES

MEDICARE PRIVATE PAYER

Hospital OP: Private Hospital OP: PrivateIf Hospital is Practice: If Hospital is Practice:

Provider: RD is provider: Provider: RD is provider:

CMS 1450 CMS 1500 CMS 1450 CMS 1500= UB04 claim^ claim or = UB04 claim^ claim or or HIPAA 837 HIPAA 837 or HIPAA 837 HIPAA 837Institu ECF* Prof ECF** Institu ECF* Prof ECF**

To Part A To Part B Carrier; To Private To PrivateIntermediary; being being replaced by Insurance Insurance

replaced by Medicare Medicare AdministrativeAdministrative Contractors Contractors..."MACs"

^ If paper claim used, must use new CMS-1500 paper claim (08-05) and new UB-04 paper claim.*Institu ECF = Institutional electronic claim **Prof ECF = Professional electronic claim

REJECTED vs. DENIED CLAIMS

REJECTED CLAIM DENIED CLAIM

Medicare returns as unprocessable. Medicare made determination thatMedicare cannot make payment coverage requirements not met;

decision until receipt of example: service is not medicallycorrected, re-submitted claim. necessary.

= INCOMPLETE Claim: If you feel this is an error,Required info is missing or can pursue payment throughincomplete (ex: no NPI #). Medicare's appeals process.

INVALID Claim: BEFORE furnishing non-coveredInfo is illogical or incorrect benefit, may give beneficiary

(ex: wrong NPI #, hysterectomy Medicare's current ABN form.billed for male pt, etc.)

STATE INSURANCE MNT—DSMT PAYMENT MANDATES for PRIVATE PAYERS

• 46 states* and DC have state insurance laws that require private payer some degree of coverage for:

– MNT, DSMT and DM-related services and supplies1

* 4 states with no laws: AL, ID, ND, OH

• Laws override any coverage limitations in health plan

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

1. http://www.ncsl.org/research/health/diabetes-health-coverage-state-laws-and-programs.aspxNational Conference of State Legislatures

CODING AND BILLING RULES OF THUMB

CODING AND BILLING RULES OF THUMB

• Never guess as to which procedure codes to use on claim!

o Do your homework with each and every insurer!

• Never select procedure code JUST because of good reimbursement rate… always remember that:

o Code must match code terminology and nature of service furnished

• Benefit’s reimbursement rules must be met 100%

• Never bill code that limits billing providers to physicians only for service furnished by non-physician ancillary staff, such as RD, CHES, MA, etc., unless insurer allows

CODING AND BILLING RULES OF THUMB

• Regarding billing “incident to physician services,” always check FIRSTwith insurer to determine IF this billing method is allowed or mandated for benefit being billed

o IF allowed or mandated, always identify insurer’s requirements for office physicians and ancillary staff

• Track your reimbursement retrospectively (quarter basis):

o For claim denials and rejections:

Identify reason why Fix problem Re-bill asap (usually have limit of 12 months)

IGNORE MEDICARE AND YOU MAY FIND YOURSELF UP A CREEK WITHOUT A PADDLE

INCREASE REIMBURSEMENT NOW! ALL IT TAKES IS A LITTLEDESIRE AND STRENGTH ON YOUR PART!

YOUR PATIENTS, PROVIDERS & STAFF

WILL LOVE 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 OVERLOAD

MARY ANN WILL NOW ENTERTAIN YOUR QUESTIONS

REFERENCES• 1. Medicare Coverage Policy Decision: Duration and Frequency of the Medical Nutrition Therapy (MNT)

Benefit (#CAG-00097N); www.cms.gov/coverage/8b3-ggg.asp• 2.Final MNT Regulations. CMS-1169-FC. Federal Register, November 1, 2001. Department of Health and

Human Services. 42 CFR Parts: 405, 410, 411, 414, and 415; www.eatright.org/cmsfinal110101.html• 3. CMS Program Memorandum, Additional Clarification for MNT Services for Beneficiaries with Diabetes

or Renal Disease. Published May 1, 2001; www.cms.hhs.gov/manuals/pm_trans/AB02059.pdf• 4. CMS Medicare Claims Processing Manual, Chapter 12, Section 190, Rev. 2282, 08-26-11 (Medicare

telehealth services and regulations for providing MNT or DSMT via telehealth).• 5. National Standards for Diabetes Self-Management Education, Mensing C, et al., Diabetes Care. 25

(Supp 1): S140-S147, 2002• 6. Expanded Coverage of Diabetes Out-Patient Self-Management Training, June 15, 2001. PM B-01-40;

www.cms.hhs.gov/manuals/pm_trans/B0140.pdf;• 7. AADE Reimbursement Primer, American Association of Diabetes Educators, 2000; www.aadenet.org• 8. Diabetes Education Services, Reimbursement Tips for Primary Care Practice, Revised June 2010,

American Association of Diabetes Educators,http://www.diabeteseducator.org/export/sites/aade/_resources/pdf/research/Diabetes_Education_Services6-10.pdf

• 9. Medical Nutrition Therapy Works tool kit, revised 2010, Academy of Nutrition and Dietetics• 10. Medical Nutrition Therapy: The Basics, Medicare MNT and Medicare MNT Coverage Expansion,

Academy of Nutrition and Dietetics, , http://www.eatright.org/mnt/• 11. Medicare MNT Provider, 2010 and 2011 monthly newsletters (provide continuous updates of the

Medicare program and its requirements, guidelines for practice, billing, compliance, etc.), Academy ofNutrition and Dietetics

• 12.CMS Program Memorandum, MNT Services for Beneficiaries with Diabetes or Renal Disease.Published August 7, 2001; www.cms.hhs.gov/manuals/pm_trans/B0148.pdf, Program Transmittals, B-01-48

REFERENCES, CONT.• 13. CMS Program Memorandum, Additional Clarification for MNT Services (includes instructions for carriers based on

NCD. Published May 1, 2002; www.cms.hhs.gov/manuals/pm_trans/AB02059.pdf, Program Transmittals, AB-02-059• 14. Legislation for Health Care Coverage for Diabetes Self-Management Training, Equipment, and Supplies: Past, Present,

and Future. Diabetes Spectrum, Daly A, Leontos C., 12(4) 222-230, 1999• 15. Expanded Coverage of Diabetes Out-Patient Self-Management Training, June 15, 2001. PM B-01-40;

www.cms.hhs.gov/manuals/pm_trans/B0140.pdf, Program Transmittals, number B-01-40• 16. Final MNT Regulations. CMS-1169-FC. Federal Register, November 1, 2001. Department of Health and Human

Services. 42 CFR Parts: 405, 410, 411, 414, and 415• 17. Medicare Program; Expanded Coverage for Outpatient Diabetes Self-Management Training and Diabetes Outcome

Measurements; Final Rule and Notice. Federal Register, December 29, 2000, 42 CFR, Parts 410, 414, 424, 480 and 498, Vol. 65, No 251, p 83129-83154

• 15. Medicare Coverage Policy Decision: Duration and Frequency of the Medical Nutrition Therapy (MNT) Benefit (#CAG-00097N),

• www.cms.hhs.gov/coverage/8b3-ggg.asp• 16. National Standards for Diabetes Self-Management Education, Mensing C, et al., Diabetes Care. 25(Supp 1): S140-

S147, 2002• 17. Web sites:• • Centers for Medicare and Medicaid Services (formerly HCFA): www.cms.gov• • Academy of Nutrition and Dietetics: www.eatright.org/mnt• • American Diabetes Association: www.diabetes.org• • American Association of Diabetes Educators: www.aadenet.org• 18. Step-by-Step Guide to Medicare Medical Nutrition Therapy (MNT) Reimbursement 2nd Edition, April 2010, Indian

Health Service, Division of Diabetes Treatment and Prevention, Albuquerque, New Mexico, www.ihs.gov/MedicalPrograms/Diabetes/HomeDocs/Training/WebBased/CKDNutrition/MNT_Reimburse_Guide_508c.pdf

• 19. Diabetes Education Services, Reimbursement Tips for Primary Care Practice, Revised June 2010, American Association of Diabetes Educators, www.diabeteseducator.org/export/sites/aade/_resources/pdf/research/Diabetes_Education_Services6-10.pdf

• 20. Diabetes Self-Management Education/Training Reimbursement Toolkit, 2013, Delmarva Foundation for Medical Care, the Disparities National Coordinating Center, under contract with the Center, for CMS

This information is intended for educational and reference purposes only. It does not constitute legal, financial, medical or other professional advice. The information does not necessarily reflect opinions, policies and/or official positions of the Center for Medicare and Medicaid Services, private healthcare insurance companies, or other professional associations. Information contained herein is subject to change by these and other organizations at any moment, and is subject to interpretation by its legal representatives, end users and recipients. Readers/users should seek professional counsel for legal, ethical and business concerns. The information is not a replacement for the Academy of Nutrition and Dietetics’ Nutrition Practice Guidelines, the American Diabetes Association’s Standards of Medical Care in Diabetes, guidelines published by the American Association of Diabetes Educators nor any other related guidelines. As always, the reader’s/user’s clinical judgment and expertise must be applied to any and all information in this document.

APPENDIX

10 STEPS TO INCREASE

PRIVATE PAYER AND MEDICAID

MNT—DSMT REIMBURSEMENT SUCCESS

Steps designed to identify payers’ benefits and benefit reimbursement rules in order for you to:

1. Increase your patient volume via: More referrals from ALL area providers More patient self-referrals

2. Increase your revenue via: Successful insurance reimbursement Pts’ out-of-pocket payments (self-pays & co-pays)

3. Increase collateral revenue for your entity via: Pts obtaining other services (lab tests, therapies)

10 STEPS TO INCREASE PRIVATE PAYER AND MEDICAID MNT-DSMT REIMBURSEMENT SUCCESS

1. Identify the area healthcare insurers you will bill:

• Medicare Part B

• Medicaid in your state

• Private healthcare plans (e.g., Blue Cross, Blue Shield, Aetna,etc.)

10 STEPS TO INCREASE PRIVATE PAYER AND MEDICAID MNT-DSMT REIMBURSEMENT SUCCESS

2. Know that each insurer has multiple health plans.

• Typically:

o Insurer has POLICY that specific benefit is covered

o Reimbursement rules (R/Rs) in policy apply to all the individualplans

o BUT, know that R/Rs can and may vary among individual plans

Example of “categories” of health plans:

• Exclusive Provider Organization (EPO) Plans

o Subscriber must use in-network doctors, specialists or hospitalsfor coverage, except in emergency.

• Health Maintenance Organization (HMO) Plans

o Coverage usually limited to care from doctors who work for, orcontract with HMO

o Generally out-of-network care not covered except in emergency

o For coverage, subscriber may have to live in service area

o Integrated care, prevention and wellness provided.

• Point of Service (POS) Plans

o Subscriber pays less if uses plan’s in-network doctors, hospitalsand other health care providers

o Referral is required from primary care doctor in order to seespecialist and not pay additional cost

• Preferred Provider Organization (PPO) Plans

o Subscriber pays less if uses plan’s in-network doctors, hospitalsand other health care providers

o No referral required from primary care doctor to use outside ofnetwork doctors, hospitals and providers; does not pay additionalcost to do so

10 STEPS TO INCREASE PRIVATE PAYER AND MEDICAID MNT-DSMT REIMBURSEMENT SUCCESS

3. Identify IF MNT-DSMT is covered by the health plans

There are ways to identify coverage!

Ways to Identify Coverage

Review all of your providers’ in-network provider-payer

contracts to identify if coverage is stipulated

Ways to Identify Coverage

Contact insurer’s Provider Relations Dept. by phone,

citing in-network provider-payer contract number, and ask

about coverage using:

Names of benefits in this slide deck, and/or

Procedure codes of benefits

Ways to Identify Coverage

Contact insurer’s Subscriber/Patient Coverage

Dept. by phone….cite subscriber’s number….and

ask about coverage, citing:

Specific names of benefits in this slide deck, and/or

Procedure codes of benefits

Ways to Identify Coverage

Access insurer’s website to determine if insurer

has secure subscriber coverage portal that can

be accessed by in-network and out-of-network providers

Ways to Identify Coverage

Access subscriber’s coverage via electronic

claims submission software that may be provided by

insurer

Ways to Identify Coverage

Insert patient’s “swipe/scan healthcare ID card” in

special card reader provided by insurer.

Keep database of results, and update regularly!

10 STEPS TO INCREASE PRIVATE PAYER AND MEDICAID MNT-DSMT REIMBURSEMENT SUCCESS

4. For each covered benefit, in each plan, identify procedurecodes for initial and follow-up

interventions

PROCEDURES CODES THAT ALIGN WITH MNT

Required by Medicare on claims for MNT

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

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

97803 MNT, reassessment, follow-up EOC, individual 15 min

97804 MNT, initial or follow-up EOC, group 30 min

G0270MNT, initial, individual, beyond 3 hours, or MNT, follow-up, individual, beyond 2 hours per 2nd referral in same year

15 min

G0271 MNT, initial, group, beyond 3 hours, or MNT, follow-up, group, beyond 2 hours per 2nd referral in same year

30 min

PROCEDURES CODES THAT ALIGN WITH MNT

S9449 Weight management classes, non-physician provider, per session

S9452 Nutrition classes, non-physician provider, per session

S9470 Nutrition counseling, dietitian visit

* CPT® copyright 2012 American Medical Association - All Rights Reserved

PROCEDURES CODES THAT ALIGN WITH DSMT

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

PROCEDURES CODES THAT ALIGN WITH DSMT

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

PROCEDURES CODES THAT ALIGN WITH MNT - DSMT

99401 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); ………………approx. 15 min.

99402 Same……….approx. 30 min.

99403 Same…….…approx. 45 min.

99404 Same…….…approx. 60 min.

99411 Same…….…group….30 min.

99412 Same…….... group….60 min.

* CPT® copyright 2012 American Medical Association - All Rights Reserved

PROCEDURES CODES THAT ALIGN WITH MNT - DSMT

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

• 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 standardsestablished or recognized by physician society, non-physician HCP society/association, or otherappropriate source

10 STEPS TO INCREASE PRIVATE PAYER AND MEDICAIDMNT-DSMT REIMBURSEMENT SUCCESS

5. If any codes covered, identify frequency (hours,visits) and time frames (calendar or rolling year) forinitial and follow-up MNT--DSMT

6. If covered, identify payable ICD-10 diagnosis codes

7. If covered, identify approved billing providers andrendering providers for MNT--DSMT

8. If covered, identify reimbursement rates

10 STEPS TO INCREASE PRIVATE PAYER AND MEDICAID MNT-DSMT REIMBURSEMENT SUCCESS

9. If covered, identify the approved places of serviceand patient eligibility (e.g., FPG >126 mg on 2 tests)

10. Know coding and billing rules of thumb

“Homework? Me?” YES!

This information is intended for educational and reference purposes only. It does not constitute legal, financial, medical or other professional advice. The information does not necessarily reflect opinions, policies and/or official positions of the Center for Medicare and Medicaid Services, private healthcare insurance companies, or other professional associations. Information contained herein is subject to change by these and other organizations at any moment, and is subject to interpretation by its legal representatives, end users and recipients. Readers/users should seek professional counsel for legal, ethical and business concerns. The information is not a replacement for the Academy of Nutrition and Dietetics’ Nutrition Practice Guidelines, the American Diabetes Association’s Standards of Medical Care in Diabetes, guidelines published by the American Association of Diabetes Educators nor any other related guidelines. As always, the reader’s/user’s clinical judgment and expertise must be applied to any and all information in this document.

REFERENCES• 1. Medicare Coverage Policy Decision: Duration and Frequency of the Medical Nutrition Therapy (MNT)

Benefit (#CAG-00097N); www.cms.gov/coverage/8b3-ggg.asp• 2.Final MNT Regulations. CMS-1169-FC. Federal Register, November 1, 2001. Department of Health and

Human Services. 42 CFR Parts: 405, 410, 411, 414, and 415; www.eatright.org/cmsfinal110101.html• 3. CMS Program Memorandum, Additional Clarification for MNT Services for Beneficiaries with Diabetes

or Renal Disease. Published May 1, 2001; www.cms.hhs.gov/manuals/pm_trans/AB02059.pdf• 4. CMS Medicare Claims Processing Manual, Chapter 12, Section 190, Rev. 2282, 08-26-11 (Medicare

telehealth services and regulations for providing MNT or DSMT via telehealth).• 5. National Standards for Diabetes Self-Management Education, Mensing C, et al., Diabetes Care. 25

(Supp 1): S140-S147, 2002• 6. Expanded Coverage of Diabetes Out-Patient Self-Management Training, June 15, 2001. PM B-01-40;

www.cms.hhs.gov/manuals/pm_trans/B0140.pdf; • 7. AADE Reimbursement Primer, American Association of Diabetes Educators, 2000; www.aadenet.org• 8. Diabetes Education Services, Reimbursement Tips for Primary Care Practice, Revised June 2010,

American Association of Diabetes Educators, http://www.diabeteseducator.org/export/sites/aade/_resources/pdf/research/Diabetes_Education_Services6-10.pdf

• 9. Medical Nutrition Therapy Works tool kit, revised 2010, Academy of Nutrition and Dietetics• 10. Medical Nutrition Therapy: The Basics, Medicare MNT and Medicare MNT Coverage Expansion,

Academy of Nutrition and Dietetics, , http://www.eatright.org/mnt/• 11. Medicare MNT Provider, 2010 and 2011 monthly newsletters (provide continuous updates of the

Medicare program and its requirements, guidelines for practice, billing, compliance, etc.), Academy of Nutrition and Dietetics

• 12.CMS Program Memorandum, MNT Services for Beneficiaries with Diabetes or Renal Disease. Published August 7, 2001; www.cms.hhs.gov/manuals/pm_trans/B0148.pdf, Program Transmittals, B-01-48

Facilitated Discussion

Chat in your questions and comments.

Press *1 on your telephone key pad to enter the teleconference queue.

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Call to Action

• Share a strategy that you learned today that you intend to put into practice. (Chat it in!)

• Identify at least one partner you can ask to join you in your DSMT efforts.

• Complete the post-event assessment: https://www.surveymonkey.com/r/VXTRWRR

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CE Credit

• Complete the post-event assessment upon exiting WebEx: https://www.surveymonkey.com/r/VXTRWRR

• It will pop up at the conclusion of the event• There is a separate evaluation required for CE that is

linked within the post-event assessment• Once you submit your CE evaluation, you will be

provided with a certificate to retain for your records• For technical assistance, please email Nikki Racelis

(nikki.racelis@qinncc.hcqis.org)

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Save the Date!

Join us for the third and final call in the Three-Part QIN-QIO Public Sharing Call Series: Going Back to Basics of Diabetes Self-Management Training

– The 2nd Thursday of December (12/13)– Topics: operations, reimbursement, and CQI for DSME/T

programs– 3:00 - 4:30 PM ET– Registration is required!

• Register separately for each call at https://qioprogram.org/qin-qio-public-sharing-calls-3-part-series

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Follow the QIO Program on Social Media!

https://twitter.com/QIOProgram

https://www.youtube.com/channel/UCP-3KliHRoKeozEs-7ohQnw

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Thank you!

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This material was prepared by Telligen, the Quality Innovation Network National Coordinating Center, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-QINNCC-02385-10/16/18