Reimbursement Index << Medicare's CCIP and ADA Request

MNT REIMBURSEMENT UPDATE: 2007

Obtaining the National Provider Identification Number

CMS is in the process of replacing all Medicare Identification Numbers (formerly known as ‘Provider Identification Numbers’) with the National Provider Identification (NPI) number. The NPI number is a unique, government issued, standard identifier mandated by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Once assigned, the 10 digit numeric NPI number stays with a provider for life. It replaces all other identifiers and is to be used on all claims and submissions, from private insurance to government transactions. So the NPI number will replace current “legacy” numbers such as providers’ MINs and Unique Physician Identification Numbers (UPINs) for physicians. Under HIPAA regulations, practitioners and organizations are required to use NPI numbers beginning May 23, 2007 (May 23, 2008 for small entities). The ADA suggests that to prepare for the change, RDs should assure that their office systems accommodate the length and composition of the NPI number. In some cases old software will not be able to handle the changes and the provider will require a version upgrade. Early users of the NPI number should check whether their claims processing software allows for two identifiers while the transition to the NPI number is occurring, and determine whether the payer is able to link both numbers to the practice. The NPI number is now required on the Medicare enrollment application CMS 855I form.

Expansion of Medicare Telehealth Services to Include MNT

In the Medicare Physician Fee Schedule Final Rule for 2005 (effective January 1, 2006), CMS expanded the list of Medicare telehealth services to include individual MNT. In addition, RDs and qualifying nutrition professionals have been added to the list of practitioners who are authorized by law to furnish and receive payment for telehealth MNT. This means that Medicare beneficiaries with diabetes or non-dialysis kidney disease who reside in rural health professional shortage areas defined by the federal government now have improved access to Medicare MNT. To obtain reimbursement, beneficiaries receiving MNT telehealth, and RDs providing it must meet the same Medicare coverage guidelines set forth in the original MNT benefit, and in addition, meet these specific telehealth regulations:

1. The RD is to use interactive audio and video telecommunications system permitting real-time communication between the distant site (where the RD is at) and the originating site (where the beneficiary is at).

2. Only individual, not group MNT may be provided.

3. The beneficiary receiving the MNT must be present at the originating site and participate in the telehealth Medicare MNT visit.

4. Originating sites authorized by law include:

a. The office of a physician or practitioner

b. A hospital

c. A critical access hospital

d. A rural health clinic

e. A federally qualified health center.

5. The originating site must either be:

a. A non-metropolitan statistical area (non-MSA)

b. A rural Health Professional Shortage Area (HPSA) or

c. An entity that participates in a Federal telemedicine demonstration project (other telecommunication equipment may be used in federal telemedicine demonstration programs conducted in Alaska and Hawaii, and in these areas, the beneficiary need not be in locations that are rural or non-MSA).

6. The RD must be licensed or certified in the state where the RD’s office is located AND in the state where the beneficiary is located (if the state has licensure or certification). If this is two different states, the RD must be licensed or certified in both states.

a. In states where there are no licensure or certification laws, the RD credential is sufficient to provide the Medicare MNT telehealth service.

7. The MNT codes G0270, 97802 and 97803 must be used when submitting claims for MNT telehealth services. The telehealth code modifier “GT” (via interactive audio and video telecommunications system) is to be added to the MNT code.

8. The claim is sent to the local Medicare carrier when the telehealth MNT originating site or the distant site is a physician’s or a RD’s office. However, it is sent to the fiscal intermediary when the originating site or the distant site is a hospital or a critical access hospital.

The telehealth MNT reimbursement rate is equal to the current amount for individual MNT. The beneficiary is responsible for any unmet deductible amount and for the co-insurance amount for originating site fee. In addition, the originating site is eligible to receive a Medicare facility fee established by CMS. Additional information on Medicare telehealth is available on the CMS web site at http://new.cms.hhs.gov/manuals/downloads/clm104c12.pdf.

Other Medicare Venues That Impact MNT Utilization

In 2003, the Medicare Prescription Drug Improvement and Modernization Act (H.R. 1) was passed into law. It contained two major new benefits which may increase utilization of the Medicare MNT benefit. The two new benefits, which will give millions of Medicare beneficiaries access for the first time to MNT services by RDs, are the Medicare Health Support Program and the Initial Preventive Physical Exam.

Medicare Health Support Program

Effective January 1, 2006, Medicare enacted a voluntary, pilot chronic care improvement program, called the Medicare Health Support (MHS) program to improve the quality of care and life for participating beneficiaries who have heart failure and/or complex diabetes among their chronic conditions. The MHS program provides to participants the disease management tools and support needed for timely and improved self-care (which includes MNT services for diabetes and renal disease when indicated) and for better adhere to the physicians' plans of care.

The U.S. Department of Health and Human Services (HHS) entered into agreements with eight Medicare Health Support Organizations (MHSOs) to provide the MHS program to approximately 180,000 select beneficiaries who have congestive heart failure and/or diabetes among their chronic conditions in eight target areas of the country:

• Oklahoma: LifeMasters Supported SelfCare, Inc. (1-888-713-2837)
• Western Pennsylvania: Health Dialog Services Corporation (1-800-574-8475)
• District of Columbia and Maryland: American Healthways, Inc. (1-866-807-4486)
  
• Mississippi: McKesson Health Solutions, LLC (1-800-919-9110)
  
• Northwest Georgia: CIGNA HealthCare, LLC (1-866-563-4551)
  
• Chicago, Illinois: Aetna Health Management (1-888-713-2836)
  
• Central Florida: Humana, Inc. (1-800-372-8931)
  
• Tennessee: XL Health Corporation (1-877-717-2247)
  

The beneficiary-related goals of the MHS program, and thus the goals of the MHSOs are to:

• Increase adherence to disease management protocols which includes evidence-based care and behavior change models…this includes MNT.
  
• Reduce hospital stays and ER visits.
  
• Help avoid costly, debilitating disease complications.
  
• Help beneficiaries manage their health holistically, including all co-morbidities, relevant health care services and pharmaceutical needs.

The MHSOs help ensure that beneficiaries seek the medical care needed to reduce their health risks and provide them with a personalized plan of care, which is to include MNT when indicated. This is accomplished by MHSO’s healthcare professionals offering help and guidance to beneficiaries, primary caregivers and family members in a variety of ways, including monitoring, decision support, twenty-four hour access to a healthcare professional and self-care group education.

Treating physicians receive regular patient status reports, alerts when beneficiaries need medical attention via results of self-monitoring and also education on disease management protocols, which is to include MNT and DSME when indicated.

It is important for RDs to know that the MHS program does not:

• Change beneficiaries’ Medicare coverage, their other health plans or their providers.
• Restrict access to other Medicare services.
• Expand coverage of MNT to other, new disease states.
• Directly recommend medical or ancillary services (such as MNT) when coordinating the beneficiary’s care. (They will defer to the beneficiaries’ physicians to refer their patients to other healthcare providers, including RD Medicare providers for MNT).
• Pay any claims on behalf of enrolled beneficiaries.
• Focus on any single disease, but will help participants manage their health holistically.

Congress included MNT as one of the education components that can be included in the disease management protocols. It is the MHSOs, however, that make the decision to add MNT to their disease management programs. The MHSOs are also to utilize local community medical resources for services required and local provider networks…this includes RDs. In the original Medicare Part B MNT legislation, RDs are cited as MNT providers. Thus, the MHS program has the potential for stimulating increased interest in, and referrals for MNT, especially in the targeted areas. CMS and ADA are emphasizing that RDs in the these areas contact their area physicians and their local MHSO to promote MNT.

Phase I of the MHS program will run for three years and cover at least 10% of Medicare beneficiaries. Phase II is in years four and five. Phase II evaluates success of Phase I via program measures such as:

• Adherence to evidence-based guidelines and MHS programs
  
• Re-hospitalization rates
  
• Beneficiary and provider satisfaction
  
• Health outcomes
  
• Financial outcomes (cost savings to the MHS program and CMS)
  

Congress will expand the MHS program if an evaluation of the program and its outcomes prove the program’s clinical and cost effectiveness. It is therefore very important that Medicare provider RDs track and clearly document their MNT outcomes (behavioral, clinical and cost-savings) on all patients, but especially on beneficiaries in the MHS program! RDs want to insure that the MHSOs DO include MNT in their disease management protocols in the future!

It is also important for RDs to know that the Medicare reimbursement rules for MNT furnished to these beneficiaries have not changed. For MNT in congestive heart failure and other diseases not covered currently in the MNT benefit, other payment arrangements are needed, such as the beneficiary paying out of pocket or his/her secondary (non-Medicare) insurance is billed. Medicare provider RDs who are members of ADA can obtain these printed materials for promoting MNT with the MHSOs in their areas, with area physicians, and with beneficiaries who are participating in the MHS program:

• Referring Your Patient for Medicare Medical Nutrition Therapy Services As Easy as 1, 2, 3
• Medicare Medical Nutrition Therapy Services
• Universal MNT-DSMT Referral Form

RDs can access these materials via the ADA website. Additional information on the MHS program can be accessed:

• By visiting the CMS web site at http://www.cms.hhs.gov/medicarereform/ccip/
• By contacting the MHSO directly; contact information is available at: http://new.cms.hhs.gov/MLNMattersArticles/downloads/MM3953.pdf.

Initial Preventive Physical Exam

Effective January 1, 2005, Medicare now pays for an initial preventive physical examination (IPPE) designed to determine physical conditions and risk factors of new beneficiaries as they become eligible for Medicare. The bill provides for screening, testing and other preventive services that include among other things, MNT services provided by a RD. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 provides for coverage of the IPPE under Medicare Part B for new Medicare beneficiaries but only if the beneficiary’s eligibility also begins on or after January 1, 2005. It also allows for payment for an IPPE not later than six months after the date the beneficiary’s first coverage period begins under Medicare Part B.

This once-in-a-lifetime examination benefit is designed to determine physical conditions of new beneficiaries as they become eligible for Medicare. The exam provides for screening and other preventive services that include among other things, MNT provided by a RD. MNT is expressly listed as one of the “other preventive services” for which the physician may make referrals based on the IPPE. Among the tests, screening and services included in the IPPE are:

• Diabetes screening blood tests
• Serum lipid tests
• Education, counseling and referral with respect to specific screenings and other preventive services, which are covered separately under Medicare Part B, including:
  • DSME
  • MNT

When MNT is referenced in the CMS regulations for the IPPE, the RD is cited as the provider of Medicare MNT for qualifying beneficiaries with diabetes and non-dialysis kidney disease. This is due to the fact that the original Medicare Part B MNT benefit identifies the RD as a provider of MNT in these disease states. Data from the screenings/exam/lab tests are used to decide whether a referral for MNT is needed.

Here is an example of how the IPPE can lead to a RD referral for MNT. The physician reviews the results of the fasting plasma glucose test. If it is > 126 mg/dl, the doctor may order another fasting plasma glucose test to confirm a diagnosis of diabetes mellitus. If the diagnosis is confirmed on the second test, the beneficiary would be referred to a RD for MNT services.

This is what the RD needs to know about the IPPE and MNT:

1. The IPPE expands utilization of the Medicare MNT benefit but does not expand coverage for MNT in other diseases besides those in the current MNT benefit: diabetes (Type 1, Type 2 and gestational), non-dialysis chronic kidney disease and the period of thirty six months following kidney transplant surgery.

2. The IPPE is to include a MNT referral when indicated, and RDs are to provide the MNT.

3. Medicare reimbursement rules for MNT furnished to these beneficiaries have not changed. For MNT in congestive heart failure and other diseases not covered currently in the MNT benefit, other payment arrangements are needed, such as the beneficiary paying out of pocket or his/her ssecondary (non-Medicare) insurance is billed.

RDs can obtain additional information on the IPPE on the CMS website at: http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp.

Expansion of the Medicare MNT Benefit

There are several diseases for which MNT has been proven medically reasonable and necessary, as well as cost-effective. Thus, in an effort to expand the Medicare MNT benefit, the Medicare Medical Nutrition Therapy Act of 2005 (H.R. 1582 and S. 604) was introduced in Congress by Rep. Fred Upton (R-MI) and Senators Larry Craig (R-ID) and Jeff Bingaman (D-NM). The act does not mandate that CMS approve expanding the MNT benefit; it only gives CMS the authority to expand the MNT benefit when there is scientific evidence that MNT will prevent or help prevent the onset and progression of more serious diseases, conditions or disorders. Dietitians can obtain further information on this Act by visiting ADA’s web site at: http://www.eatright.org/cps/rde/xchg/ada/hs.xsl/advocacy_386_ENU_HTML.htm

New MNT Payment Structure and Reimbursement Rate Effective 1/1/07

The reimbursement rates for Medicare MNT are based on Medicare’s current Physicians’ Fee Schedule. Up through 2006, CMS paid 85 percent of the Physicians’ Fee Schedule amount. Effective in 2007, this rate has changed. The change is based on the fact that CMS has, for the first time, set “work values” for the MNT CPT codes, due in part to a more transparent methodology to calculate practice expense costs for Medicare Part B services. CMS’ MNT payment rates for initial MNT (97802) include a slightly higher amount for Medicare RD providers working in private practices or physicians’ offices (non-facilities) compared with the MNT payment rates for Medicare RD providers who work in hospitals (facilities). The agency has recognized that RDs in private practices have different practice and overhead costs for their solo practices. These costs are part of the hospitals overhead and do not apply to hospital outpatient-based RDs. This change in how the MNT reimbursement rates are calculated is a significant step forward for Medicare RD providers. It acknowledges RDs’ professional work effort involved in providing the service, and more importantly changes the code values and thus the payment levels. This will result in significant improvements in payment levels for the MNT code values in a phase-in process between 2007 and 2010. Once these code methodology changes are fully implemented in the year 2010, RD Medicare providers will still see small to moderate increases in MNT payments compared with present day reimbursement rates. Other changes involve different payment amounts for initial MNT (97802) and follow-up MNT (97803). The follow-up code value is now slightly less than the initial code. The follow table outlines MNT codes values changes for 2007:

Medicare 2007 Physician Fee Schedule MNT Code Values

* CMS defines non-facility setting as physicians’ offices, patients’ homes, freestanding imaging centers, and independent pathology labs. Facility settings include hospitals, ambulatory surgical centers, and skilled nursing facilities.

Where to Obtain Current Rates in Geographical Area

Medicare provider RDs are to keep abreast of any changes in the Physicians’ Fee Schedule each year so that their financial planning and budgeting are more accurate. The websites of the ADA and of CMS are excellent resources to accomplish this task. These websites also have a listing of Medicare’s MNT reimbursement rates for each region of the country.

New Education and Training CPT Codes with Implication for Nutrition Services

Effective January 1, 2006, the American Medical Association approved three new CPT procedure codes* that can potentially be used for nutrition education and training services (not MNT) provided by RDs and billed to private payers. Reimbursement is not only contingent on private payers’ acceptance of the codes, but also on the RD’s adherence to the payers’ specific coverage guidelines for non-MNT nutrition services. These codes are not reimbursable by Medicare at this time; therefore, RDs should not use them on claims sent to Medicare.

* Note: CPT codes, descriptions and material only are copyright @2000 of the American Medical Association. All Rights Reserved.

These codes are intended for use for education and training for patient self-management for the treatment of established illnesses, diseases or to delay co-morbidities, the purpose of which is to teach the patient or caregivers) how to effectively self-manage the patient’s illnesses in conjunction with the patient’s professional health-care team. The ADA has written an excellent document that compares and contrasts the differences between MNT and nutrition education/self-management training; it is accessible from ADA’s website at: http://www.eatright.org, members’ only section. Click on ‘Food and Nutrition Information’ on the horizontal navigation toolbar, then click on ‘Medical Nutrition Therapy’ on the vertical toolbar, and then on ‘MNT vs. Nutrition Education (08/09/2006)’. The RD may wish to contact the private payer plans for whom she/he is a provider to discuss the possible use of these new codes.

By: Mary Ann Hodorowicz, RD, LD, MBA, CDE
Mary Ann Hodorowicz Consulting, LLC
Reimbursement Chair, Illinois Dietetic Association and
Nutrition Entreprenuers DPG

hodorowicz@comcast.net
708-359-3864
www.maryannhodorowicz.com

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last updated 2/11/07