REIMBURSEMENT POLICY

CMS-1500

Registered Dietitians and Home Health Specialties

Billing Evaluation and Management Codes Policy

Policy Number

2011R0112B

Annual Approval Date

10/13/2010

Approved By

National Reimbursement Forum

 

IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY

You are responsible for submission of accurate claims.  This reimbursement policy is intended to ensure that you are reimbursed based on the code or codes that correctly describe the health care services provided.  UnitedHealthcare reimbursement policies may use Current Procedural Terminology (CPT®*), Centers for Medicare and Medicaid Services (CMS) or other coding guidelines.  References to CPT or other sources are for definitional purposes only and do not imply any right to reimbursement.

This reimbursement policy applies to all health care services billed on CMS 1500 forms and, when specified, to those billed on UB04 forms.  Coding methodology, industry-standard reimbursement logic, regulatory requirements, benefits design and other factors are considered in developing reimbursement policy.

This information is intended to serve only as a general reference resource regarding UnitedHealthcare’s reimbursement policy for the services described and is not intended to address every aspect of a reimbursement situation.  Accordingly, UnitedHealthcare may use reasonable discretion in interpreting and applying this policy to health care services provided in a particular case.  Further, the policy does not address all issues related to reimbursement for health care services provided to UnitedHealthcare enrollees.  Other factors affecting reimbursement may supplement, modify or, in some cases, supersede this policy.  These factors may include, but are not limited to: legislative mandates, the physician or other provider contracts, and/or the enrollee’s benefit coverage documents.  Finally, this policy may not be implemented exactly the same way on the different electronic claims processing systems used by UnitedHealthcare due to programming or other constraints; however, UnitedHealthcare strives to minimize these variations.

UnitedHealthcare may modify this reimbursement policy at any time by publishing a new version of the policy on this Website.  However, the information presented in this policy is accurate and current as of the date of publication.

UnitedHealthcare uses a customized version of the Ingenix Claims Editing System known as iCES Clearinghouse (v 2.5.1) to process claims in accordance with UnitedHealthcare reimbursement policies.

*CPT® is a registered trademark of the American Medical Association

 

Proprietary information of UnitedHealthcare. Copyright 2011 United HealthCare Services, Inc.

 

Application

This reimbursement policy applies to services reported using the 1500 Health Insurance Claim Form (a/k/a CMS-1500) or its electronic equivalent or its successor form. This policy applies to all products and to all network and non-network health care professionals. This includes non-network authorized and percent of charge contract health care professionals.

 

Policy

Overview

This policy describes the correct coding methodology for reporting of services performed by Registered Dietitians and Home Health Specialties.

Reimbursement Guidelines

The Current Procedural Terminology (CPT®) book has specific guidelines that give the following instruction: "Select the name of the procedure or service that accurately identifies the service performed."

The National Correct Coding Initiative Policy Manual gives the following instruction: "Procedures should be reported with the most comprehensive CPT code that describes the services performed."

 

There are a wide variety of Current Procedural Terminology and Healthcare Common Procedure Coding System (HCPCS) codes that specifically and accurately identify and describe the services and procedures performed by Registered Dietitians and Home Health Specialties.

 

UnitedHealthcare will not reimburse evaluation and management services (CPT codes 99201-99499) when reported by Registered Dietitians or Home Health Specialties.

Registered Dietitians

Registered Dietitians most commonly perform services and procedures such as medical nutrition therapy and education, training, and patient self management. CPT and HCPCS codes exist that accurately identify and describe these services and procedures, which are to be reported by non-physicians. Examples include, and are not limited to, CPT codes 97802-97804 and 98960 – 98962 and HCPCS codes G0108, G0109 and G0270.

The CPT book instructs physicians performing medical nutrition therapy and education, training, and patient self management services to report the appropriate evaluation and management or preventive medicine service codes. Consistent with CMS and CPT coding guidelines, UnitedHealthcare will not reimburse Registered Dietitians for evaluation and management services (CPT codes 99201-99499).

Home Health Specialties

Home Health Specialties are nonphysician healthcare professionals who perform a wide variety of services and/or procedures for patients in a residential setting. Typically home health services and procedures are part of a plan of care previously established under the direction of a physician. There are specific CPT and HCPCS codes that accurately identify and describe the services and procedures performed which are performed by nonphysician home health specialties. Examples include, and are not limited to, CPT codes 99500-99602, and HCPCS codes G0151-G0161, S5497-S5523 and S9208-S9379. Evaluation and management services (CPT codes 99201-99499) do not most accurately describe these services and procedures. Consistent with CMS and CPT coding guidelines, UnitedHealthcare will not reimburse Home Health Specialties for evaluation and management services.

 

Definitions

Education and Training for Patient Self Management

Educational and Training services teach the patient how to effectively self-manage the patient's illness(s)/disease(s) or delay disease co morbidity(s).

Home Health Specialties

Home Health Specialties are nonphysician healthcare professionals who perform a wide variety of services and/or procedures for patients in a residential setting. Typically home health services and procedures are part of a plan of care previously established under the direction of a physician.

Medical Nutrition Therapy

Medical Nutrition Therapy (MNT) includes nutritional diagnostic therapy and counseling services primarily provided by a registered dietitian (RD) for the purpose of managing an acute or chronic condition or disease.

Residential Setting

A residential setting includes a patient’s residence including, but not limited to, assisted living apartments, group homes, nontraditional private homes, custodial care facilities, or schools.

 

Questions and Answers

1     

Q: Is it appropriate for a non-physician Registered Dietitian performing Medical Nutrition Therapy to report this service with CPT code 99401?

 

A: No.  CPT code 99401 is an evaluation and management code which Registered Dietitians should not use to report services.  There are more accurate codes that identify and describe Medical Nutrition Therapy to be reported by non-physicians, such as, CPT 97802.

2     

Q:  Is it appropriate for non-physician Home Health Specialties performing a service in a patient’s residence to report 99348?

 

A:  No. 99348 is an evaluation and management code which Home Specialties professionals should not use to report services. There are more specific CPT and HCPCS codes that accurately identify and describe the services and procedures performed by nonphysician home health specialties.

 

Resources

American Medical Association, Current Procedural Terminology (CPT®) and associated publications and services

 

Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS Release and Code Sets

 

Centers for Medicare and Medicaid Services, National Correct Coding Initiative (NCCI) publications

 

History

2/14/2011

Policy Name Change: Registered Dietitians Billing Evaluation and Management Codes Policy changed to Registered Dietitians and Home Health Specialties Billing Evaluation and Management Codes Policy

Policy Change: Home Health Specialties Section added. Codes Section Removed.

Policy Verbiage Change: Overview Section and Registered Dietitian Section updated.

Questions and Answers: Q&A #1 and Q&A #2 added

1/3/2011 – 2/13/2011

Annual Policy Version Change Only

11/15/2010

Policy Approval Date Change (no new version)

8/30/2010 – 1/2/2011

New policy format; no changes in intent or functionality

3/15/2010 – 8/29/2010

Publication of Policy

 

Proprietary information of UnitedHealthcare. Copyright 2011 United HealthCare Services, Inc.