4/12/2017 MAINTAINING A FINANCIALLY STABLE DIABETES EDUCATION PROGRAM CONFLICT OF INTEREST AND DISCLOSURES OBJECTIVES

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1 MAINTAINING A FINANCIALLY STABLE DIABETES EDUCATION PROGRAM AMY SALO, MS, RDN, LDN, CDE DIABETES EDUCATION COORDINATOR AND NUTRITION FACULTY RUSH UNIVERSITY MEDICAL CENTER CONFLICT OF INTEREST AND DISCLOSURES Consultant for Medtronic Diabetes as Certified Product Trainer OBJECTIVES At the conclusion of this program, participants will be able to: Implement various strategies to market your program and services Improve reimbursement through proper referrals and billing codes Assess ability to implement additional services to benefit program 1

2 PRE-TEST 1. True or false, you can bill Medicare for DSME/T services even if you re not accredited through AADE or ADA. 2. How many initial hours of DSME/T and MNT is a Medicare patient allowed in the first year? a) 5 hours DSME/T and 2 hours MNT b) 10 hours DSME/T and 3 hours MNT c) 2 hours DSME/T and 2 hours MNT d) 10 hours DSME/T and 1 hour MNT 3. What is required to be allowed to bill for individual DSME/T for patient? a) Special need such as hearing, vision, etc. b) New insulin start c) No group session offered within 2 months d) All of the above THE GOAL FOR DIABETES EDUCATION PROGRAMS Get our patients in the door, provide exceptional education and care and get reimbursed to the maximum potential so our doors remain open! HOW DO WE DO THAT? Accreditation Marketing Proper billing and orders Consider extra revenue 2

3 ACCREDITATION You MUST be accredited to bill Medicare and get reimbursed! ADA and AADE offer accreditation options Must submit annual status report and reapply every 4 years MARKETING We have to be good at marketing our programs Keys to marketing: Tell people who/what/where/when Go to where your patients are Follow-up MARKETING WITHIN YOUR ORGANIZATION Demonstrate your benefit To providers Pay for performance measurements Teaching patients basic skills that MD doesn t need to teach Offer services within clinic Have walk-ins available for new insulin starts or meter teaches Become a resource for insurance questions 3

4 MARKETING WITHIN YOUR ORGANIZATION Demonstrate your benefit To the facility Referrals to specialists and PCP s Decrease ED costs for the uninsured and underinsured MARKETING IN THE COMMUNITY Give talks to local organizations Senior housing, community centers, libraries, faith centers Health Fairs Offer to write articles for local newspapers, Facebook, newsletters for groups PEOPLE ARE COMING IN THE DOOR NOW WHAT? Have the proper order completed Bill using appropriate codes/diagnoses Offer additional services to patients 4

5 DSME/T ORDERS Medicare requires the following things for DSME/T orders: Diagnosis Number of hours allowed Plan of care Topics of discussion Individual or group education Provider signature and NPI To be valid, orders must be place BEFORE the visit Must be ordered by provider who TREATS patient s diabetes WHO CAN PROVIDE THE SERVICE? Must be a Medicare provider Must be an accredited program Recognized program through ADA Accredited through AADE Providers include: CDE s, RD, RN, or pharmacist HOW IS IT BILLED? Registered Dietitians are Medicare recognized billing providers if they have an NPI CDE s, pharmacists, or RN s cannot bill directly Can bill under RD or under program NPI number 5

6 ORDERS MUST BE UPDATED For initial education: 10 hours are allowed by Medicare Must be used within 1 year of initial visit If you don t use it, you lose it New order placed for follow-up visits in 13 th month New order must be placed at the beginning of the calendar year for follow-up visits INITIAL EDUCATION 10 hours allowed and 9 hours must be in a group setting Individual is allowed for 1 hour or for entire 10 hours if the following criteria are met: No group visit scheduled within 2 months Additional insulin training is listed on DSMT order (must indicate hours needed) Provider documents barrier requiring need for individual vs group: Hearing, vision, language barrier, cognitive barrier, physical limitation FOLLOW-UP EDUCATION Medicare allows for 2 hours of education per calendar year after initial education If 2 hours aren t used by 12/31 of that year, hours are lost Follow-up hours can be provided as group OR individual without documented need 6

7 CONFUSED YET? DSMT HOUR USAGE EXAMPLES November 2017 July 2018 December 2018 Initial 1 hour completed Completes 9 hours of group education Eligible for DSMT f/u, new order required January 2017 January 2018 February 2018 Initial 1 hour completed Completes 9 hours of group education Eligible for DSMT f/u, new order required FOLLOW-UP HOURS USAGE January 2017 March 2017 January 2018 First DSMT f/u session completed Completes remainder of 2 hours Eligible for 2 hours f/u, new order required November 2017 December 2017 January 2018 First DSMT f/u session completed Completes remainder of 2 hours (or loses hours) Eligible for 2 hours f/u, new order required 7

8 MEDICAL NUTRITION THERAPY Can be performed and billed by RD s only Only covered by Medicare for the following diagnoses: Kidney disease, diabetes, rental transplant within 3 years Doesn t cover prediabetes or obesity.yet! You cannot bill for MNT and DSMT for a patient on the same day Can be individual or groups MNT ORDER REQUIREMENTS Order must include the following: Narrative diagnosis or ICD 10 code Signature of MD or DO who treats diagnosis listed Order date Name of patient Order must state MNT or Medical Nutrition Therapy MNT HOURS Medicare covers 3 hours initially and 2 hours in follow-up years New order required each calendar year Additional hours can be requested if needed due to change in status or diagnosis (G-codes are used for these hours of billing) Not covered if patient is receiving maintenance dialysis 8

9 MNT Hour Usage Examples January 2017 May 2017 January 2018 First initial session completed Remainder of 3 hours completed Eligible for MNT f/u, new order required November 2017 December 2017 January 2018 First initial session completed Remainder of hours (2 or 3) must be used Eligible for MNT f/u, new order required DSME/T OR MNT? MNT = nutritional, diagnostic, therapeutic and counseling services provided by an RD DSME = overall guidance related to all aspects of diabetes self-management and glycemic control Nutrition is a topic within DSMT but does not include specific meal planning or nutritional recommendations BILLING FOR SERVICES DSME/T CPT Codes: 30 minute increments Covered by 80/20 by Medicare G0108 (individual) 1 unit - $53.27 G0109 (group) 1 unit - $

10 BILLING FOR SERVICES MNT Codes 15 minute increments Covered 85/15 by Medicare (initial) $32.89 (facility) $35.04 (non-facility) (follow-up) $27.53 (facility) $30.03 (non-facility) (group) $15.37 (facility) $16.09 (non-facility) MAXIMIZING YOUR RESOURCES FOR REVENUE How can you draw in more patients? Offer more services Prediabetes program Pump/CGM trainings Weight management programs Medical Nutrition Therapy DIABETES PREVENTION PROGRAM Medicare recently announced coverage for DPP program starting 1/1/2018! 10

11 DIABETES PREVENTION PROGRAM How to be a CDC recognized program: Uses CDC-approved curriculum Must offer a program delivered over 1 year 16 sessions in first 6 months 6 sessions in last 6 months Submit data on patients progress Use lifestyle coaches Must have program coordinator MAXIMIZING YOUR RESOURCES FOR REVENUE Pump/CGM Trainings Become a CPT for various pumps/cgm s and train patients in the clinic vs. using pump trainers from the company Bill both DSME and CGM insertion for pump/cgm trainings 2 hours of DSME + CGM insertion/training could be reimbursable between $ Weight Management Program Consider cash pay for classes Medical Nutrition Therapy Typically reimbursed at a higher rate than DSME Alternate diagnoses for non-medicare patients MAXIMIZING YOUR RESOURCES FOR REVENUE Professional CGM use Consider purchasing a CGM system (or 2) for your office Potentially costly up front but provides significant revenue source if utilized Reimbursement rates: (insertion of sensor) $ (interpretation must be done by MD/NP) $44-85 If no MD or NP available to bill for 95251, you can complete the interpretation and review with patient 11

12 PROFESSIONAL CGM CGM costs up front: ipro2 Professional CGM starter kit (5 sensors and serters plus transmitter) $ pays for itself after about 7 patients Freestyle Libre Pro Reader Kit (1 Reader kit and 4 sensors) $199 pays for itself after 1 patient Dexcom Professional CGM Platinum Professional (receiver, charger, USB) plus transmitter $748 pays for itself after about 4 patients TELEMEDICINE (DHHS MEDICARE LEARNING NETWORK) Originating site (where the patient is located and receiving services) of the patient must be: A county outside of a Metropolitan Statistical Area A rural Health Professional Shortage Area (HPSA) located in a rural census tract Originating sites: Physician office Hospital Critical Access Hospitals (CAHs) Rural Health Clinics Federally Qualified Health Centers Hospital-based or CAH-based Renal Dialysis Centers (including satellites) Skilled Nursing Facilities (SNFs) Community Mental Health Centers (CMHCs) TELEMEDICINE Telemedicine Eligible Providers: MD, PA, NP, CNS, Nurse midwife, psychologist, social worker and RD. Must have technology to have an interactive audio and video system that allows for real-time communication Reimbursement: Originating site can bill Medicare for facility fee Provider completing services bills DSME/T or MNT codes Reimbursed at same rate as face-to-face 12

13 TAKE HOME MESSAGE Diabetes education programs are a needed resource but are no good if they are closing due to finances Demonstrate your value within your organization and community Utilize your own department s resources and skills to offer services that benefit the patient and the bottom line POST-TEST 1. True or false, you can bill Medicare for DSME/T services even if you re not accredited through AADE or ADA. 2. How many initial hours of DSME/T and MNT is a Medicare patient allowed in the first year? a) 5 hours DSME/T and 2 hours MNT b) 10 hours DSME/T and 3 hours MNT c) 2 hours DSME/T and 2 hours MNT d) 10 hours DSME/T and 1 hour MNT 3. What is required to be allowed to bill for individual DSME/T for patient? a) Special need such as hearing, vision, etc. b) New insulin start c) No group session offered within 2 months d) All of the above POST-TEST 1. True or false, you can bill Medicare for DSME/T services even if you re not accredited through AADE or ADA. 2. How many initial hours of DSME/T and MNT is a Medicare patient allowed in the first year? a) 5 hours DSME/T and 2 hours MNT b) 10 hours DSME/T and 3 hours MNT c) 2 hours DSME/T and 2 hours MNT d) 10 hours DSME/T and 1 hour MNT 3. What is required to be allowed to bill for individual DSME/T for patient? a) Special need such as hearing, vision, etc. b) New insulin start c) No group session offered within 2 months d) All of the above 13

14 REFERENCES 1. Department of Health and Human Services Center for Medicare and Medicaid Services. Manual Update on Medical Nutrition Therapy (MNT) Services- Manualization. September 9, Guidance/Guidance/Transmittals/downloads/R673CP.pdf 2. Department of Health and Human Services Center for Medicare and Medicaid Services. CMS Manual System Pub Medicare Benefit Claims Processing Transmittal May 25, Guidance/Guidance/Transmittals/downloads/R1255CP.pdf 3. Department of Health and Human Services Center for Medicare and Medicaid Services. Medicare Learning Network Telehealth Services. November MLN/MLNProducts/downloads/TelehealthSrvcsfctsht.pdf 4. Department of Health and Human Services Center for Medicare and Medicaid Services. MLN Matters Number: MM5433 Revised. May 25, MLN/MLNMattersArticles/downloads/MM5433.pdf 5. Department of Health and Human Services Center for Medicare and Medicaid Services. CMS Manual System Pub Medicare Benefit Policy. May 28, Guidance/Guidance/Transmittals/downloads/R13BP.pdf QUESTIONS?? 14