Frequently Asked Questions: Medicare Claims Processing

Frequently Asked Questions: Medicare Claims Processing

1.  Is the Medicare MNT benefit payment linked to out-patient prospective payment system (OPPS) or Ambulatory Payment Classifications (APCs)?  If so, will payment for the Medicare MNT benefit for diabetes andrenal be delayed because of CMS's software system problems?

Payment for the Medicare MNT benefit (applicable to outpatient services and billed to Medicare Part B) is not tied to the outpatient prospective payment system (OPPS) or Ambulatory Payment Classifications (APCs). According to CMS,  the Medicare MNT benefit, "payment in the hospital outpatient department will be made under the physician fee schedule, not under the hospital outpatient prospective payment system."1
All inpatient nutrition services for Medicare Part A are bundled under the conditions of participation and cannot be billed separately. For hospital patients who are Medicare beneficiaries, supplies may or may not be reimbursed in a medical facility based on medical necessity and the facilities' billing system. Submitting inpatient claims for nutrition services to private insurers or other third party payers is dependent on the insurer/payers' contract. If the facility is a JCAHO accredited facility, RDs must provide inpatient nutrition services to meet quality standards.

2.  What billing form should be used?

The CMS1500 form, or electronic equivalent should be used for Medicare Part B billing. The CMS1500 form can be purchased from the American Medical Association, US Government Printing Office and office supply stores.  CMS has indicated the UB92 form can also be used if outpatient hospitals do not have systems in place for submitting claims on the CMS1500 form. If claims are submitted on the UB92 or its electronic equivalent, the claims are sent to the fiscal intermediary (FI).

3. Do RDs need a Medicare provider identification number (PIN) and will RDs bill under technical services or professional services?

RDs need a PIN and the Medicare Part B MNT services are billed as professional services, submitted to Medicare carriers on a CMS1500 form. CMS representatives have indicated RDs who want to provide MNT services under the new Medicare MNT benefit for diabetes and kidney disease must enroll in the Medicare program and obtain a personal identification number. Based on an amendment to the Balanced Budget Act that expanded Part B coverage, RDs now have the authority to independently treat upon a physician referral, Medicare beneficiaries (for MNT for Diabetes and renal disease as defined by the MNT regulation) in all settings except skilled nursing and hospital inpatient facilities and bill Medicare for their services. Congress gave the right for RDs to bill Medicare directly for services provided to outpatients. Consequently, when RDs are employed by a hospital, their direct, professional services for MNT for diabetes and kidney disease as defined by the MNT regulation are billed to Medicare Part B.

4.  Do I need to fill in the physician’s UPIN number on the CMS1500 form?

Yes, on the CMS1500 form, the treating physician’s UPIN must be provided on Medicare MNT claims for diabetes and non-dialysis kidney disease. In addition, a physician order is required to initiate the MNT service for Medicare beneficiaries with diabetes or kidney disease. The physician, physician’s office staff, or billing department can provide you with the physician’s UPIN.

5.  What is the timeframe for submitting Medicare Part B claims (bills) to my carrier?

Practitioners must submit claims within 12 months from when the service was provided. RDs as Medicare Providers are required to submit claims to the carrier, even if the patient wants to submit the claims. Patients cannot submit claims to Medicare.

References

1. Federal Register, 42 CFR, Part 405 et al, Vol 66, No. 212, November 1, 2001; "Medicare Program; Revisions to Payment Policies and Five-Year Review of and Adjustments to the Relative Values Units Under the Physician Fee Schedule for Calendar Year 2002: Final Rule," pg 55279.

2. CMS Program Memorandum, 8/10/01: "Special Payments for Outpatient Prospective Payment Systems (OPPS) Due to Delay in Implementing System Updates" accessed 12.20.01, http://www.medicare.gov/Publications/Search/Results.asp?PubID=02118&Type=PubID&Language=English