Medicine Dish: Invest in Nutrition — Medical Nutrition Therapy and Reimbursement

[Kelly Acton] I’m a strong believer in MNT, I think coupled with good diabetes care that I as a physician can deliver, the nurses deliver, the physical therapist with the foot care, the eye care, all those things, it’s an integral part of it. [Dolores Addison] Both my parents are actually diabetic, so it’s one of the reasons why I became a Registered Dietitian. Both my grandmothers were diabetic as well and died from complications of diabetes and one of the main reasons I believe they suffered as much as they did was because of lack of education. [Edith Clark] We have a dietetic internship here. And I think not only are we very proud of that but I think as we provide a learning opportunity for these interns to, at that very early stage before they become Registered Dietitians, to learn about medical nutrition therapy, its reimbursement, and how important it is in a business world and certainly as we align the business world with the medical world in this day and age to support that financially. [Roslyn Bolzer] I work on an Indian reservation that I think has the second highest poverty in the nation. And by doing medical and nutrition therapy and getting the reimbursement that is available, this will maybe allow us to provide additional services to the people who would not have had it otherwise. [Kitty Marx] Welcome to this month’s Medicine Dish broadcast. I’m Kitty Marx, Director of the CMS Tribal Affairs Group and your host of Medicine Dish. Today’s broadcast will focus on medical nutrition therapy and reimbursement potential in Indian country. Medical Nutrition Therapy or MNT is effective in the management and prevention of chronic diseases. Medicare and other third party payers reimburse for MNT services in treating diabetes and kidney disease. Yet in some clinical settings, MNT services are being underutilized. Our presenters today will offer suggestions for building an effective MNT program. You’ll find out what MNT is, why it’s important and how to foster a partnership of administrators, health care providers, business office staff, and Registered Dietitians. You’ll also get practical guidance on how to bill Medicare for these services to sustain your MNT program. All this and more on today’s installment of Medicine Dish. [music] Again, welcome to Medicine Dish. As I mentioned earlier, today’s topic is medical nutrition therapy and reimbursement. Before we begin I want to take a moment to briefly review what the Medicine Dish is and how you can use the information. The Medicine Dish introduces various topics pertinent to health care programs operated by the Indian Health Service, tribes, tribal organizations and urban Indian health programs. Medicine Dish is broadcast on the third Wednesday of every other month at 1:30 Eastern Time and can be seen over the Web through a partnership with the National Institutes of Health at The next show will air on April 20th. All shows are archived at and are easy to access if you can’t watch at the regularly time or want to review the information. Look for previous shows under past events, select “Trainings and Meetings”, and then select “CMS – Centers for Medicare and Medicaid Services”. And now you can find the Medicine Dish on YouTube, just go to, and search for Medicine Dish. We have a new Nation Builders feature for you. Nation Builders are tribal leaders and other principals involved in securing access to high quality health care for Indian people. For this show, we’re sharing our interview with Dr. Yvette Roubideaux, Director of the Indian Health Service. Dr. Roubideaux is a member of the Rosebud Sioux Tribe of South Dakota. As an Assistant Professor of Family and Community Medicine at the University Of Arizona College of Medicine, she conducted extensive research on American Indian, Alaska Native health issues with a focus on diabetes. She also served as the Co-Director of the Special Diabetes Program for Indians Demonstration Project. Here’s Dr. Roubideaux’s interview with our Medicine Dish moderator David Nolley. [David Nolley] Thanks Kitty, we are so pleased to be joined by Dr. Yvette Roubideaux, the Director of the Indian Health Service. Welcome to Medicine Dish. Let’s start with the status of Indian health care today. From your perspective, how would you describe the current state of Indian health care in the United States? [Dr. Roubideaux] Well I think the current state of American Indian, Alaska Native health in the United States is better but we still need improvement. The Indian Health Service was established in 1955 and since then it has created access to health care in places where there would otherwise be no other options. And so we’ve seen great improvement in the health status of Indian people over time. However, health disparities still exist in our communities, so more needs to be done. [David Nolley] What are your hopes for the future, if they need health care over the next five years? [Dr. Roubideaux] My hopes for Indian health care over the next five years are that we can change and improve the organization so that we can improve the quality of and access to care for the patients that we serve. [David Nolley] And how realistic is that? [Dr. Roubideaux] I think it’s realistic. Actually I think that our staff and our patients and the tribes that we serve are very excited about the atmosphere of change that we are in today with this new administration and all of the support that we’re seeing in Congress and the support from our tribes and our patients. Everybody wants to see the Indian Health Service change and improve, so that’s why one of my major priorities is to reform the Indian Health Service. And I think we can make progress over the next few years. [David Nolley] Oh, that’s good to hear. Well, what are the greatest challenges facing Indian health care currently? [Dr. Roubideaux] Well we have many challenges. The Indian Health Service was as I said established many years ago and has been trying to address very serious health challenges of this population, which is actually growing very fast, so the demand is up. In addition we have been struggling with the resources that we have to meet our mission because of rising health care costs and medical inflation. We’ve also had the challenge of increased chronic diseases, which are a great strain on our system because they’re so costly and require very complicated care. And the other challenge that we face within our rural and remote communities, we have a hard time recruiting and maintaining primary care physicians, especially since there’s a growing shortage of them in the United States these days. [David Nolley] Well what success stories exist and how can they best be applied to other situations? [Dr. Roubideaux] Well I think we have a lot of success stories. The Indian Health Service is a champion of doing more with less especially in the area of providing culturally appropriate and competent care. Many of our facilities serve American Indians from several different tribes and with varying levels of beliefs in their traditions, speaking different languages or individuals who are more acculturated. So as a result, we have to be very flexible with the care that we provide and make sure that we’re explaining to our patients that they’re getting good, quality care. We also have great examples of providers who are able to provide high quality care with little equipment in very rural areas. And we have tribal programs that are learning how to collaborate with other organizations and partners in the community and federal agencies to try to provide better health care. So I think we’re a great example of an organization that has people who do a lot with little resources. [David Nolley] What is your message to health care providers in Indian country? [Dr. Roubideaux] My message to health care providers in Indian country is that I’m very grateful for the services that they provide and I’m especially grateful that they are willing to do that under challenging circumstances. And that I do believe that we provide quality health care and that I know that they have great ideas to provide better health care if we move forward with our IHS reform efforts. So I’m very grateful for all that they do and I’m looking forward to seeing some unique, creative and innovative ideas as we move forward to change and improve the Indian Health Service. [David Nolley] What is your message to CMS staff regarding the agency’s relationship with American Indian and Alaska Native populations? [Dr. Roubideaux] Well I’m very grateful to all the CMS staff who recognize that American Indians and Alaska Natives are served by the programs that CMS runs. And I’m also grateful to the staff for understanding the unique, special political relationship that the tribes have with the Federal government and the willingness to work with the tribes and the patients in our communities. I’m also very grateful for CMS’ efforts to outreach and teach our patients that they have the resources, such as Medicare, Medicaid and the CHIP programs available to them, so that they have more health care choices. I’m grateful to CMS and its partnership with the Indian Health Service as well. [David Nolley] What efforts are under way to increase funding? [Dr. Roubideaux] Well, we’re very grateful that in Fiscal Year 2010 both the President and Congress recognized that IHS needs some more resources to meet its mission and so we received a 13 percent increase in our budget, which was the largest increase in the past 20 years. So we’re very grateful for that. It seems like there is a general understanding that we do need more resources based on sort of historically being under funded. We are working on that through our budget formulation process as well to justify that need. And we’re also educating our tribes on what the needs may be. But we’ve also realized that for our facilities in addition to the appropriations that they receive, they also can bill for Medicare, Medicaid, CHIP, and private insurance. So we’re working on improving our billing practices and making sure that we’re maximizing third party reimbursements. And those will help us bring in more resources for better health care for American Indians and for Alaska Natives. [David Nolley] Great, is there anything else you’d like to share with our Medicine Dish audience? [Dr. Roubideaux] Well yes, I have two other things that I would like to share. First is that I don’t know that many people realize that while the Indian Health Service serves 1.9 million American Indians and Alaska Natives in this country, it’s primarily in rural areas. And there are many more American Indians and Alaska Natives that aren’t near Indian Health Service facilities and so they rely on a lot of other resources and Medicare, Medicaid, and CHIP really do play an important role for them. The other thing you mentioned before was innovation and I didn’t want to leave without talking about the Special Diabetes Program for Indians. It’s a Congressional appropriation that’s been around for about 10 years and it has some of the most innovative programs that we have in Indian country. Diabetes is a serious problem for American Indians and probably the reason that we have it is there has been such a great change in the environment within which American Indians and Alaska Natives used to live. 100 years ago we didn’t have diabetes but now that we have it and some of the highest rates in the world what we’re trying to do is both treat it and prevent it. And our almost 400 funded grant programs under this Congressional appropriation have done some really great jobs teaching people how to treat their diabetes and prevent the complications. And to bring in culture and tradition to help get us back to healthy ways of living, so that we can prevent diabetes like we used to before. [David Nolley] Okay, well thank you so much for joining us. It’s been a pleasure to talk with you. [Dr. Roubideaux] Thank you very much. [David Nolley] You’re certainly welcome. [Kitty Marx] I hope you enjoyed Dr. Roubideaux’s insights. We look forward to her continued leadership in improving health care for Indian people for years to come. And now, let’s turn to the topic for today’s Medicine Dish broadcast, Medical Nutrition Therapy. We’re pleased to bring you leaders from the field to talk about the benefits of MNT, increasing patient access to MNT services and steps you can take to ensure reimbursement for services. This show features members of the IHS MNT Action Team sharing their expertise. For more information contact team members by e-mail at [email protected] or call. The newly revised IHS Step-By-Step Guide to MNT Reimbursement will be available soon. To order a copy, please go to the Division of Diabetes Treatment and Prevention Online Catalog at What is MNT? MNT is a Medicare reimbursable service and it is defined in CMS regulations as “nutritional, diagnostic, therapy and counseling services provided by a Registered Dietitian or nutrition professional for the purpose of managing disease. To describe the need for MNT in Indian country, we’re pleased to bring you Lieutenant Samantha Interpreter, a U.S. Public Health Service Registered Dietitian working at the Kayenta Service Unit on the Navajo Reservation. Samantha. [Samantha Interpreter] Thank you. This is a great opportunity to collaborate with the Centers for Medicare & Medicaid Services to share important information with our providers serving American Indians and Alaska Natives. [Native greeting] Today I would like to share a story with you. I was born on the Navajo Reservation to my parents, Lillie Leonard and Earl Interpreter. Growing up my mother told me stories of how life used to be on the reservation. A typical day for my mother would be a day of herding sheep, gathering firewood and water for meals, also milking the goats for milk to drink or to make blue corn pancakes. My mother did not eat until all the elders ate. This meant sometimes she would only eat one or two meals a day. Today my mother Shima, is a very strong and healthy woman. And I am proud to say that I am her daughter. Life has changed so much since those times. Today I work in a clinic as a Registered Dietitian in Kayenta, Arizona. Every day I see my people being diagnosed with diabetes, kidney disease, liver disease, depression and obesity. Today on the reservation life is very different from when Shima was growing up. Many people enjoy eating at flea markets. Unfortunately the foods are often very high in calories, fats and sugar. Another challenge on the reservation is the high number of fast food establishments and the lack of affordable fresh fruits and vegetables. I help but I am only one dietitian for 59,000 patients. Our patients need greater access to medical nutrition therapy services. I am so fortunate to be able to help spread this message today because I really do believe that if there were more Registered Dietitians on the reservation, we could help prevent and control chronic disease. The National Indian Health Service Medical Nutrition Therapy Action Team is working hard to reach health administrators and providers to share the message of the overwhelming need for patients to have access to medical nutrition therapy. Research shows that MNT, or Medical Nutrition Therapy works. Studies from the Indian Health Service show that patients receiving MNT from a Registered Dietitian have better diabetes and lipid control. Other studies have also shown MNT reduces the cost of diabetes treatment by reducing physician visits, hospital admissions and medications. Another great benefit that you’ll learn about in today’s Medicine Dish show is that MNT makes money. Third party payers will reimburse for MNT services for diabetes and kidney disease. We are here to help you learn how to maximize medical nutrition therapy reimbursement for your facility, starting today. [Kelly Acton] In terms of diabetes care, medical nutrition therapy is one of the cornerstones of treatment, MNT medical nutrition therapy. It’s a, in my view, it’s almost a requirement to get the best diabetes care to a client because the physician not matter how well he or she is trained, has really so little training in nutrition consultation compared to an RD or a person who can deliver MNT. And so even the best physician answering a patient’s questions about nutrition doesn’t get it right in the same way that the RD professional who is trained in delivering MNT can do. And you have to function to do the best diabetes care within a multi-disciplinary team. And in my opinion, I rely as much on the nurses who screen patients and who do some of the diabetes education, physical therapist or whomever is doing the foot care, the eye doctors, the whole team even the dentists because dental care is real important part of diabetes care. All of us form a team but an integral part of that is the nutrition consultant and the nutrition specialist. And delivering that medical nutrition therapy as part of the treatment, I think is just as important as the medications I prescribe. It’s that multi-disciplinary team approach that says the patient struggling with this; he’s doing well at that, that allows us to tailor the care. But I wouldn’t know that because patients don’t tell physicians everything. So you often wouldn’t know that unless you have those other team members telling you the truth. I think there are far too few Registered Dietitians compared to other health professionals in our system and in the general population. It sometimes boggles my mind because our administrators, while they are trying to cut costs and manage funds, and I respect that it’s very difficult to do, but it seems like such short-sighted thinking to not hire the types of professionals who could prevent diabetes, who could help us treat the diabetes so that it’s better controlled instead of inflating the pharmacy budget. You know I think an RD is not that expensive compared to what we spend on pharmaceuticals. And I think that there’s ample evidence that good medical nutrition therapy delivered by a professional can reduce the amount of medications that we are taking. So I think it is very short-sighted when we fail to hire the professionals who can deliver that therapy. It makes me very sad. If you hire an RD who can deliver medical nutrition therapy, you get that person to work with the business office, you maybe use your Special Diabetes Program for Indians funding or some other source of diabetes funding, and tribes are being more and more successful these days of getting more of that funding. Use it in a preventive way to hire an RD, bring that person in to deliver this kind of expertise that no one else on your staff has, doesn’t matter if you have lots of doctors, lots of nurses, I can guarantee they do not have the kind of training that an RD does who can deliver MNT. You are going to realize cost savings down the road. And somehow that concept, I think we need to spread the word about that concept. It’s the same as preventing amputations. It may be even more effective because we’re not just talking about taking people who have the disease already and treating them, although that’s what MNT is. But there’s no nutritionist worth his or her degree who’s not going to also come into a community and talk about how to prevent diabetes. And I think that kind of information is going to trickle down through families, through communities and that’s where we’re really going to start to see prevention of diabetes occurring. If the nutritionist, the RD can make it easy for the doc, first of all, don’t be shy, go to medical staff meetings, meet with the providers and explain to them, you know I understand that you guys are professionals and you know what you’re talking about in terms of these things. But I have tips and tricks that I can teach your patient to help him or her to maximize the goals that you and that patient have set. But people know if they’re armed with the right information and the right tools, they can make more good choices then they are making today. And that’s really what it’s about, it’s not about you have to change everything for ever more, but it’s about well today I made three more good choices than I made yesterday. And that’s how behavior change happens. It happens in small steps but if you don’t have the information you can’t even begin to think that way. So that’s why I think the nutrition professionals who keep on top of this and who try to stay one step ahead of the food marketing that’s you know, that’s permeating our whole society. They can point that out to people, you know, well when you’re sitting there hungry in the evening and your watching television have you ever thought about muting the ads? You know, I have heard a nutritionist say that, it’s like what I did with my children. Soon as I heard someone say that I demanded, you can watch cartoons if you mute the ads because I didn’t want someone in their face telling them what they should eat that was full of sugar and awful stuff. And I think there’s just simple little tools like that, I’ve heard nutritionist say things like, just reduce the size of your plate and it doesn’t feel like you don’t have as much food. And I’ve had more patients come in and tell me, that was so helpful. Now my plate still looks full. No, but who knows those kinds of tricks, most physicians certainly don’t unless an RD taught it to them. I know it now. [laughs] [pause] [Tammy Brown] Here we’ve got this new benefit, a benefit called Medical Nutrition Therapy reimbursement from Medicare. And I’m thinking wow if we could generate some revenue, if dietitians could generate revenue and they say that our service pays for itself would the clinic, for example, be willing to hire one more dietitian in view of the fact that there’s been funds created to support that position. And when I first started to talk about it, this is an area that dietitians aren’t accustomed to, kind of the business side of their profession, except those maybe that are in private practice. But those of us who have worked for large institutions never had to worry about the billing and you know the documentation except for the purposes of communicating with other health care providers. So I began to go around and kind of describe the benefits that Medicare offers and also provide guidance into how dietitians could you know make steps toward becoming a Medicare provider, how to document it, how to bill, how to track. And eventually that led into wanting to put it into step-by-step guide which is what we did early in 2006. And of course lots has changed and it’s been updated and now we’ll be releasing one in 2011. [Susan Jones] Hello, my name is Commander Susan Jones. I’m a Clinical Dietitian at the Northern Navajo Medical Center. In 2008, I had a great opportunity to spend six months working with the Tribal Affairs Group at CMS. During this time I was able to join a very talented team under the direction of Captain Tammy Brown, Indian Health Services’ Division of Diabetes Treatment and Prevention, Medical Nutrition Therapy Action Team. Under her direction the team has developed a Step-by-Step Guide to Medicare Medical Nutrition Therapy Reimbursement that I would like to encourage all administrators and providers to support their dietitians to review and implement. Today I would like to present some key points to remember from this guide. The Step-by-Step Guide to MNT Medicare Reimbursement is designed primarily for Indian health care system Registered Dietitians. The purpose of the guide is to help you learn how to document MNT services and outcomes, work with your health care facility to bill for MNT services, take an active role in seeking MNT reimbursement and market your service within the Indian health care system and to your tribal members. Roslyn Bolzer, Diabetes Coordinator at the Kyle Clinic in Kyle, South Dakota is going to share with us some of the first steps in the MNT reimbursement process. [Roslyn Bolzer] To become recognized as a dietitian Medicare provider requires one to fulfill two key steps. The first step is that you become a Registered Dietitian or advanced nutrition professional. To meet that criteria, you have to have completed a Bachelor of Science degree or an advanced degree in nutrition. One must then, following that, complete a dietetic internship or 1,200 hours of supervised dietetic practice or the AP4 Program. At this point, you are a Registered Dietitian and you seek employment within a state. At that time you must apply for licensure or certification in that state. Now you are a Registered Dietitian, you’re working in a state but now you need to become that recognized Medicare provider. To do this you must first apply to the Centers for Medicare and Medicaid Services. To do that you need to complete the national, individual provider application form. This is a form that allows CMS the opportunity to review your credentials. Are you even eligible to receive this Medicare provider number? The second form that you complete must be the form numbered 855I. This is a form that allows CMS to issue you a Medicare number. And the last form that you must complete is the 855R. The R allows Medicare to reimburse your facilities for your medical nutrition therapy services. Everyone, I encourage you to remember if you have any trouble with your form, contact your business office because they’re very capable in helping your complete these forms. [Susan Jones] Thank you, Roz. The second step is to make friends with the business office. Introduce yourself to the business office; ask permission to observe the process; ask for tips on proper documentation; learn about CPT codes, ICD 9 codes, referral forms and super bills, CMS form 1500, the health insurance claim form; and learn what other tips your business office can offer. [Edith Clark] It has to be a coming together of the different stakeholders, one being the patient business office, certainly administration and leadership as well as the Registered Dietitian and Medical Records because everybody plays a key role. The business office I think plays obviously a very critical role in helping us to work through this and if there are questions or comments or problems or concerns, that’s the time when the dietitians and the business office can come together. And on a, at least every six months, we get the business office will run a report that comes directly to me as the director of this department that shows how much reimbursement our facility, the dietitians — how much was billed and much was reimbursed during that six month time period. You know, that’s a time when you can work together, you know, is there something that we can do better. But it’s critical no matter what facility you’re in, to develop partnerships with the business office, develop partnerships with administration and with your Supervisor of the Medical Records Department because everybody, nobody can do it by themselves. Dietitians can’t do it alone; the business office can’t do it alone. It really is a puzzle where every piece is in place and then it works. [Susan Jones] Now that we have a relationship with the business office, let’s review step three to maximize the MNT reimbursements: obtain treating physician referral and authorization for patient visits. Lieutenant Kelli Wilson, Director of Community Health and Diabetes at the Wewoka Service Unit understands this process very well. [Kelli Wilson] The treating physician must make the referral for eligible Medicare patients who have a diagnosis of diabetes or renal disease or who are within six months post kidney transplant. I was able to develop a relationship and establish a rapport with providers at my service unit and I think that’s really important for Registered Dietitians to be able to do that. Simply providing information on what services RDs can provide and how it benefits the patient and the patient’s health in the long run. [Susan Jones] Thank you, Kelli. Let’s now move on to the fourth step for MNT reimbursement: Learn more about Procedural CPT codes and diagnosis codes, ICD-9 for reimbursement. As I dietitian I need to understand that I may bill for MNT services for diabetes and chronic kidney disease, three hours of MNT in the first calendar year, two hours of MNT follow-up in subsequent calendar years. MNT hours cannot be carried over into next calendar years. MNT services can be individual or group. Additional hours have been allowed when physicians changes diagnosis/ plan of care or when you need a new referral from a physician, no maximum amount of hours. Because of this I need to understand the CPT codes for MNT reimbursement. Use code 97802 for an individual patient’s initial assessment and intervention visits, up to three hours in calendar year. Use code 97803 for a patient’s follow-up visits up to two hours. Use code 97804 for group visits with two or more individuals up to three hours for each patient for the initial calendar year. I need to understand G codes are used when additional service is needed. Use G0270 for an individual patient’s reassessment and subsequent interventions after completion of the three hours of basic coverage (code 97802) already provided in the same calendar year. Use G0271 for patient’s group reassessment and subsequent interventions following completion of the three hours of basic coverage (code 97804) already provided in the same calendar year. I need to understand ICD-9 codes for MNT, 250 series codes for diabetes, 585 series codes for chronic kidney disease, V42 series codes for kidney transplant and finally I need to be aware of a great opportunity for reimbursement if I use tele-health services. Diane Phillips, Program Director of the Indian Health Tele-Nutrition Program is here today to tell us about this great service. [Diane Phillips] With the Indian Health Service tele-nutrition is definitely a great avenue to increase access to care. Most sites are in very remote areas and a lot of the sites have difficulty finding qualified health professionals. So tele-nutrition allows a good avenue to provide nutrition services to sites that would otherwise not receive it. The tele-nutrition program began in the fall of 2006. And it started out as a pilot project with the Crow Agency in Crow, Montana and due to the success of that program then we expanded services to six other sites within Arizona, Nevada and Montana. And essentially what tele-nutrition is, it’s basically the same type of services that dietitians usually provide, MNT, other nutrition services however we utilize the use of video conferencing equipment. I also use WebEx as well. I use WebEx in order to display educational materials to the patient and also through that it means I am able to show patients their electronic health record, we’re able to access the Internet and use the various resources that are available on the Internet as well. In order to bill for tele-nutrition services, essentially the process is the same as a dietitian would bill for face-to-face services with the exception is that we do have to add a tele-health modifier which would be the GT modifier, which is the audio and video telecommunications modifier which signifies that is tele-health and it’s also done in real time. We’re not able to bill for store and forward services for dietitians. So it would just be a GT modifier, everything else essentially is the same. The only exception would be in order for a beneficiary to qualify for tele-health coverage, they have to reside in an area that it is deemed a health professional shortage area. And that area also has to not be classified as a metropolitan statistical area. And essentially most of the IHS sites would qualify within this area but in order to verify if your sitet meets that criteria on the CMS web site there is a link that will take you to a map that will show your state and it will show it you fall into that region. Essentially all of IHS, most of our beneficiaries, the only exception possibly would be a patient living in Phoenix receiving the service from Phoenix. But most of our sites were providing the services to more remote areas. We had such success at the Crow Service Unit with the tele-nutrition program that they want to expand that model all over Montana but we also found, we weren’t trying to find this but indirectly we have found that we have a much higher show rate with our tele-nutrition visits than our face-to-face visits. So they also wanted to capture on that model as well and especially for the Billings area, they have a very low show rates and so they wanted to look into well why, how come our show rates, you know is 80 percent for tele-nutrition and 20 percent for other services. And even 20 percent for face-to-face nutrition visits. So they wanted to look into why, what was so successful about tele-nutrition, what was it about it that made patients want to come in for those visits opposed to other visits. Some of the exciting news on the horizon for tele-nutrition services and tele-health services is as of calendar year 2011, Medicare has approved coverage of additional tele-health services. A few of those include group MNT services. Previously we were only reimbursed for individual MNT visits via tele-health. So now we’re able to bill for group visits as well as individual visits for MNT along with group and individual visits for diabetes health management training. So those are definitely two exciting additional coverages for dietitians, so it will help to expand our services as well as expand our opportunities for additional reimbursement and revenue. [Susan Jones] Thank you, Diane. Tele-health sounds like a great opportunity to help our patients. Let’s now move on to step five: how to maximize MNT reimbursement. Documentation, documentation, documentation. To obtain reimbursement for MNT services you must properly document the service that you provide. Medicare and other government insurance programs, private sector insurance companies and health care accrediting agencies require that you submit complete and accurate documentation. We’re fortunate to have Leslye Rauth, Registered Dietitian and Clinical Application Coordinator of Office of Information Technology explain this step and how easy documentation can be using the electronic health record. [Leslye Rauth] Documentation for medical nutrition reimbursement requires three components. The first component would be the provider name and the date. The second component would involve the medical nutrition intervention need. The only two billable services at this time are diabetes and renal related diseases. The third component would be the face-to-face time spent with the patient and the unit time in and time out. Indian Health Service to document medical nutrition therapy in the electronic health record realm, we use the consult and it’s electronically generated. In some facilities, they use a paperless referral form to refer patients for Medical Nutrition Therapy. Medical Nutrition Therapy units are recorded on the charge ticket in the electronic health record. That’s reflected from the face-to-face time with the dietitian and the patient that’s captured by the time in and time out and the units are captured there in the charge ticket. In Indian Health Service for Medical Nutrition Therapy reimbursement begins after the encounter. The dietitian will mark on the super bill the time in, the time out and the units and the CPT code. From there the electronic bill will generate to the billing office and they will process it for reimbursement. The Indian Health Service National Medical Nutrition template is designed for the dietitian to use with electronic health record. It is based on the American Dietetic Association nutrition care process. They define as the framework of the critical thinking for the dietetic professional. So it helps you capture the patient encounter, the needed requirements for medical nutrition therapy, and also captures the patient care plan so that the patient can be treated. [Susan Jones] Thank you, Leslye for teaching us about proper documentation. Let’s move on to step six: tracking MNT services and then reimbursement. Tracking MNT services and reimbursement provides a wealth of information for you and your MNT practice. Consider developing or adapting a tracking system that will help you record patient visits, the MNT services you provide and reimbursement for MNT services. Captain Tammy Brown shares with us some great ideas on MNT tracking systems. [Tammy Brown] In the past we have provided some examples of ways to track and what to track, but I believe that needs to be determined on a local level. We certainly don’t want to add busy work to the dietitian when she’s got, you know, 10 patients lined up to see her. But I think the real reason is to, you know, if you’ve gone through the work of providing the service, documenting the service, the billing staff has submitted the claim, you want to make sure that you are getting paid. And if you’re not, figure out why and correct it. Those claims can be resubmitted and you don’t want it to be a source of lost revenue for the clinic itself. So the kinds of items that you would want to track would be the name of the patient, what was provided, the amount of time spent, the referring physician, the name of the dietitian, the appropriate numbers associated with those individuals, you would want the date of the service. So those are the important pieces. The one other thing that I wanted to mention about tracking and why it’s important is that in the first year that — the initial year that MNT is ordered — there is a limit to the number of hours that can be provided to a single patient and that’s three hours. And if the person needs additional hours the dietitian will have to return to the provider and get a second referral. And so that’s another way to make sure that you don’t exceed the hours and therefore some of what you’ve provided them is not billable. Same thing with subsequent years, there’s a limit to the number of hours that are provided. So you just want to stay on top of those things to be sure that the patient is getting what they need but also the clinic can benefit from the reimbursement. Well if you’re tracking the claim and it comes back and you learn that something was missing in the claim submission, you can correct it, add that information and resubmit. As I understand it there are very common documentation problems that can be easily corrected. Other reasons why a claim might be denied might be exceeding the number of hours that were allowed for that time frame. And so that again is another real important item to be tracking and again how a dietitian does that with their business office is up to them. We’re just concerned that they’re aware of what’s happening with the claims and if they’re being denied to have that opportunity to correct it and get a full reimbursement. [Susan Jones] Well I bet you’re wondering, what’s the final step for maximizing your MNT reimbursement. It’s market your MNT services. Tammy Brown and Brenda Broussard, a top Indian Health Services consultant, have some great tips for marketing MNT services. [Tammy Brown] MNT is foundational to the management of most chronic disease. Nutrition is essential and no other therapy can work as good if nutrition isn’t part of the treatment plan. And dietitians are the most highly qualified to provide MNT because of our training and experience. We take what the science of nutrition and translate it into everyday practical ideas for patients to be able to change their behaviors and you know integrate nutrition guidelines into practice. I think that, you know, tell somebody to lower their fat intake by 10 percent, well what does that mean. So we can help provide them with everyday examples and let them select from a menu of choices. And make it their decision so that it works in the long term. [Brenda Broussard] Well I am going to give you some examples of how I market my services just in the clinic. When I go to clinic, I announce myself because we have various pods where we work. We have about — we have eight physicians, two nurse practitioners and a physician’s assistant. I see who’s working that day and just say I am here today. I have a panel of patients that I am going to see but if you especially have a newly diagnosed diabetes patient, just know that I’m here and I’m going to be here all day. So first of all having a presence and establishing a relationship. So when I find some good diabetes articles, like for example every year at the beginning of the year in January, the American Diabetes Association always publishes the clinical practice guidelines which a lot of physicians don’t necessarily get all of those guidelines. I get copies of that and I distribute it. Other things I do to market, probably the biggest one is, when I see that there’s a need for and the patient is willing to change medications, just going in and having a conversation with the physician right there, physician, you know, we have a discussion, and more often than not the physician writes the prescription, gives it to me to make a copy, give it to the patient. So it’s all done in one, if you will, one-stop shopping. [Susan Jones] Now that you’ve seen all seven steps on how to maximize MNT reimbursements, I bet you’d love to hear from some providers who are just getting started with this process and those who have been doing it for years. [Shanna Moeder] Kodiak Area Native Association is a tribal facility that receives IHS dollars. And I believe we’re in step five which is documenting Medical Nutrition Therapy in the step-by-step guide. We learn about this in school and it sounds easy. It seems easy. And then I get to a site where I’m the only dietitian and I have to go and meet my billing office and figure out who exactly needs to get me what I need to get to be able to reimburse, reimbursement dollars. I have the understanding that we get reimbursement dollars for diabetes patients and also chronic kidney disease patients. But some of the things we’ve come across is just getting the provider numbers and then having everything fall into place of correct super billing, having the correct documentation. And I think just everything clicking in place has been some of the biggest challenges because I feel like I am doing what I am supposed to be doing on my side but for some reason we’re just not, we’re missing a step in getting those reimbursement dollars. What I would advise to someone who would be in my position today, retro them back a few years, is I would say, you know, just get in and read the information. Read the step-by-step guide, know where you need to go and then go seek the right people in the billing office. Maybe seek out a mentor if there’s an older dietitian in another facility. And really just stick to it and figure out what you need to do to make sure everything is happening to, making sure that you get those dollars back we’re allowed to get as dietitians when we provide those services. [Stefanie McLain] In order to monitor collections, you need to be able to track collections. I see a patient, do a consult, they bill for that consult, the claim goes through, the claim gets paid. That’s all kind of the way that it goes in a nutshell. So we need to figure out what’s been billed for and what’s been collected for. And you, it’s imperative that you come up with a tracking system to track that, to track those collections. And that’s where we’re at there at my clinic right now is actually coming up. I am actually working on a tracking system right now, but I don’t have it in place yet. So I don’t know actually how much is being collected. But I know that funds are being collected. Don’t give up on your business office, OK. If you can’t get through to them in the beginning, keep trying, keep trying to communicate with them, keep trying to go in. We just sometimes we’ll go into our business manager’s office and talk to her about concerns that we have. Maybe issues that need to be resolved and she doesn’t know that we have those issues and we don’t really know what, why there are some things going on or not being done. So I think that’s a big key too, is because all of the billers have to answer to somebody and that usually is a business manager. So the business office manager plays a key role in you being able to communicate to the billers. And I know that even though it might not be a Registered Dietitian’s job, so to speak, to know the billing end of it, that’s a great — it’s really good to know that. Because I have actually gathered information and told the billing or showed the billing office information that they didn’t know. And it was billing, you know, it was something that I felt like a biller should know because I knew it and I was a Registered Dietitian. So I think that knowing the ins and the outs of claims that can be billed and when they can be billed and when they have to, you know, what the time span is for them to be sent in. Even just kind of getting familiar with how the process is done, most claims are generated through a computer, knowing how that process goes I think is important as an RD. Because that gives you an inside track as to how the billing is done, kind of what the time frame is and I believe that gives you justification if they say that it’s too time consuming, you can come back with, you know, something a little bit more concrete. Because you have an insight as to how time consuming it is. And it’s different, different for Medicare, different for Medicaid, different for third party resources, the billing process. So I think the more you know about that, the better it is, but communication and being, you know, constantly communicating with your billing office is important. Keeping that, the communication line open and not getting on their bad side. It’s a really. That’s the number one piece of advice that I could give because they’re the ones who do it for you. [Revondolyn Scott] If you have not checked to see if you’re a provider yet as a Registered Dietitian, go to the business office and see if you’re a provider. Because of the fact that for a period of time I’ve been a provider for CMS services but I was not aware that I could be a provider also for the state. So if you don’t know for sure, go check it out and see. Just don’t assume that they’re billing your services. My advice that I would share with others in regards to MNT reimbursement is take the time to build that relationship with the business office staff. They’re a wonderful resource. They have knowledge on, tips on how you can properly document your services, as well as they can keep up the data for you for your collection of how much money has been received for MNT services that were billed. I think that when it comes down to building a relationship, regardless of its dealing with the community or the business office, is that you are just going to have to take the time out to just go over there, introduce yourself, get to know them, find out what information is needed and how can you assist them to make sure that you’re getting the maximum amount of money back for the services that you’re providing. [Dolores Addison] Well as the Tucson Area Diabetes Consultant and as a Registered Dietitian, I have really been able to see the benefits of Medical Nutrition Therapy for patients especially those with diabetes. Medical nutrition therapy provides patients with the tools that they need in order to control their disease. MNT reimbursement is actually something that can be a bit of a struggle at first. It does involve the work and the effort from different departments within a service unit. But we do know that the dietitian can provide the service unit with reimbursement dollars that can be a significant amount, doing what they do best which is to help their patients in their efforts to control their diabetes and or any other chronic disease. I would recommend to my colleagues out in the field to get to know the process of reimbursement, speak to your business office people, get to learn what it is that they do and how you can help them make reimbursement for medical nutrition therapy easier for them. [Edith Clark] Our success stories, I think first of all I would like to say center around the amount of money that we’ve been able to collect because it has allowed us to justify to administration that that position in that clinic is necessary from a monetary point of view. And we’ve always known that it has been necessary as in a nutritional standpoint. If they’ve got Registered Dietitians on their staff, to network within and maybe just have a sit down meeting and say you know, I’ve been hearing about this medical nutrition therapy reimbursement, how do you think it will affect our facility, can we do it, what would be our challenges, what would be our — the plus, the pros and the cons of this? Again I think it’s that communication that’s critical because there maybe just pieces that they’re just not quite as familiar with, and if they partner and learn from the dietitians and also maybe learn from the patient business office, maybe even talk to some of the administrators at some of the facilities where it’s up and running. And say, did you have problems with this, how could you have fixed this and just through networking to help them kind of get over that rough spot and then I think they’ll look back and say I’m glad that we did this because it really works. [Susan Jones] MNT services play an important role in preventing and managing chronic disease. Increasing your Medicare reimbursement for these services will help your business operations. The guide serves as a tool helping to get reimbursed for your services. We understand that you’ll face challenges. The MNT Action Team is here to assist. Contact any of our MNT team members that you heard from today for help getting started at your facility. [Kelly Acton] This therapy is so effective. It reduces hemoglobin A1Cs, it reduces lipid levels; it helps people control their blood pressure. It’s been shown in our system to improve blood pressure control, diabetes control. It’s been shown in scientific studies to work, so I don’t really understand the resistance to that other than maybe it’s we’re not getting the word out. So I am hoping that this will help that. [end of transcript]

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