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A Vision of the Future for Physician Practice in Nutrition

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A Vision of the Future for Physician Practice in Nutrition
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    http://pen.sagepub.com/  NutritionJournal of Parenteral and Enteral  http://pen.sagepub.com/content/34/6_suppl/86SThe online version of this article can be found at: DOI: 10.1177/0148607110378306 2010 34: 86S JPEN J Parenter Enteral Nutr  McClaveJoel V. Brill, David August, Mark H. DeLegge, Refaat Hegazi, Gordon L. Jensen, Charles W. Van Way III and Stephen A. A Vision of the Future for Physician Practice in Nutrition  Published by:  http://www.sagepublications.com On behalf of:  The American Society for Parenteral & Enteral Nutrition  can be found at: Journal of Parenteral and Enteral Nutrition  Additional services and information for http://pen.sagepub.com/cgi/alerts Email Alerts:  http://pen.sagepub.com/subscriptions Subscriptions: http://www.sagepub.com/journalsReprints.nav Reprints:  http://www.sagepub.com/journalsPermissions.nav Permissions:  What is This? - Dec 13, 2010Version of Record >>  by guest on October 11, 2013pen.sagepub.comDownloaded from by guest on October 11, 2013pen.sagepub.comDownloaded from by guest on October 11, 2013pen.sagepub.comDownloaded from by guest on October 11, 2013pen.sagepub.comDownloaded from by guest on October 11, 2013pen.sagepub.comDownloaded from by guest on October 11, 2013pen.sagepub.comDownloaded from by guest on October 11, 2013pen.sagepub.comDownloaded from by guest on October 11, 2013pen.sagepub.comDownloaded from by guest on October 11, 2013pen.sagepub.comDownloaded from by guest on October 11, 2013pen.sagepub.comDownloaded from by guest on October 11, 2013pen.sagepub.comDownloaded from by guest on October 11, 2013pen.sagepub.comDownloaded from   86S  Journal of Parenteral and Enteral Nutrition  Volume 34 Supplement 1November 2010 86S-96S© 2010 American Society for Parenteral and Enteral Nutrition10.1177/0148607110378306http://jpen.sagepub.comhosted athttp://online.sagepub.com T he purpose of this article is to review the history and current state of reimbursement for nutrition-related services, focusing primarily on Medicare, its impact on the physician practice of nutrition, and the opportunities for the practice of nutrition care by physicians. Although this discussion is focused on Medicare, we note that most com-mercial payers base their fee schedules and coverage policies on Medicare. Medicaid is administered on a state-by-state basis, where most programs provide lower reimbursement than Medicare and more restrictive coverage policies. The points expressed in this article can and should be general-ized to all entities providing health insurance to the U.S. population at large. From 1 Predictive Health, LLC, Phoenix, Arizona; 2 Department of Surgery, University of Medicine and Dentistry of New Jersey, New Brunswick, New Jersey; 3 Department of Medicine, Medical University of South Carolina, Charleston, South Carolina; 4  Abbott Nutrition, Columbus, Ohio; 5 Department of Nutritional Sciences, Penn State University, University Park, Pennsylvania; 6 Department of Surgery, University of Missouri Kansas City, Kansas City, Missouri; and 7 Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky.Received for publication March 11, 2010; accepted for publica-tion June 21, 2010. Address correspondence to: Joel V. Brill, MD, Predictive Health LLC, 6245 N. 24th Parkway, Suite 112, Phoenix, AZ 85016-2024; e-mail: joel.brill@gmail.com. History of Medicare and Payment Systems Health insurance for the aged, popularly known as Medicare, has had a broad impact on the living patterns of Americans, young and old. Yet the idea of government health insurance antedated the Medicare law by many  years. For some time, social security officials had been troubled because the social security system could not fulfill its basic objective, namely to protect against the greatest single cause of economic dependency in old age—the high cost of medical care. Although the first health insurance bill was introduced in Congress in 1935, it took 30 years—until 1965, when Medicare was passed—for this to be addressed. Through this process a program eventually emerged that proved acceptable to a majority of the public and lawmakers in Congress, one that has seen a number of changes and refinements over the sub-sequent decades.The genesis of private insurance began in 1929, when the prototype prepaid hospital plan on which Blue Cross plans were later based was created at Baylor University in Dallas, Texas, when a businessman offered a way for 1300 schoolteachers in Dallas to finance 21 days of hospital care by making small monthly payments.  Around the same time, the Blue Shield concept was grow-ing out of the lumber and mining camps of the Pacific Northwest, where serious injuries and chronic illness were common among workers in these hazardous jobs. One obstacle that may discourage physician trainees from pursuing a career in clinical nutrition is the perception that such physician practice does not generate sufficient income.  A review of the history of Medicare and the current payment system for healthcare services by the U.S. government is essential to understand which members and what services provided by a nutrition support team (NST) will be reim-bursed. Patients who require nutrition therapy tend to have multiple comorbidities, which should allow for a higher level of billing under evaluation and management codes. Despite the fact that an intact NST improves outcome and helps ensure patient safety, such teams may not be able to func-tion independently and remain financially sustainable. Hospital administration should be mandated to support an institutional nutrition service. Strategies to define mal-nutrition and identify measures of quality nutrition care should help demonstrate the value and promote the impor-tance of a functioning NST. (  JPEN J Parenter Enteral Nutr  . 2010;34:86S-96S) Keywords: practice management; coding; reimbursement; Medicare; Medicaid; billing  A Vision of the Future for Physician Practice in Nutrition  Joel V. Brill, MD 1 ; David August, MD 2 ; Mark H. DeLegge, MD 3 ;Refaat Hegazi, MD 4 ; Gordon L. Jensen, MD 5 ; Charles W. Van Way III, MD 6 ; and Stephen A. McClave, MD 7 Financial disclosure: none declared. Physicians Summit  The Future for Physician Practice in Nutrition /   Brill et al 87S Employers who wanted to provide medical care for their workers made arrangements with physicians, who were paid a monthly fee for their services. 1  Since 1965, the private payment system has converged extensively with the government system, where reimbursement may often be higher but coverage policies are often similar.The passage of Medicare provided the groundwork for the payment system that the majority of healthcare providers labor under today. Today, Medicare is a health insurance program for the following:  • People age ≥ 65 years  • People age <65 years with certain disabilities  • People of all ages with end-stage renal disease (permanent kidney failure requiring dialysis or a kidney transplant)There are 3 parts to Medicare:  • Part A, hospital insurance—helps cover inpa-tient care in hospitals, including critical access hospitals and skilled nursing facilities (not cus-todial or long-term care). It also helps cover hospice care and some home healthcare.  • Part B, medical insurance—helps cover doctors’ services and outpatient care, including outpa-tient hospital services, ambulatory surgery cent-ers, and diagnostic imaging facilities. It also covers some other medical services that part A doesn’t cover, such as some of the services of physical and occupational therapists, some home healthcare, and drugs infused in a physi-cian’s office under physician supervision.  • Part D, prescription drug coverage—private companies provide the coverage. Beneficiaries choose the drug plan and pay a monthly premium. 2 Supplementary Medical Insurance (SMI) consists of Medicare parts B and D. Medicare also has a part C, which serves as an alternative to traditional parts A and B coverage. Under this option, beneficiaries can choose to enroll in and receive care from the private plan called Medicare Advantage and certain other health insurance plans that contract with Medicare. The costs for such beneficiaries are generally paid on a prospective, capitated basis from the part A and SMI part B trust fund accounts.Medicare pays for beneficiaries’ medically necessary healthcare needs as long as they fit into one of the broadly defined categories of benefits established in the Social Security Act (“the Act”). Among other things, these categories include commonly used medical services and supplies such as physician visits, inpatient hospital stays, diagnostic tests, durable medical equipment, and pros-thetic devices. Although the Act provides for broad cover-age of many medical and healthcare services, it does not provide an exhaustive list of all services covered. 3  Similarly, the Act generally does not specify which medical devices, surgical procedures, or diagnostic services the program covers. The Act states that the program cannot pay for any supplies or services that are not “reasonable and nec-essary” for the diagnosis and treatment of an illness or injury. [Specifically, the law states that Medicare cannot pay for any supplies or services that are not “reasonable and necessary for the diagnosis and treatment of an ill-ness or injury or to improve functioning of a malformed body part.” 42 U.S.C. §1395y(a)(1)(A).]Medicare coverage of parenteral nutrition (PN) and enteral nutrition (EN) therapy is contained in section 1861(s)(8) of the Act, the prosthetic device benefit, which provides that “the term ‘medical and other health services’ means any of the following items or services: . . . prosthetic devices (other than dental) which replace all or part of an internal body organ (including colostomy bags and supplies directly related to colostomy care), including replacement of such devices, and including one pair of conventional eyeglasses or contact lenses furnished sub-sequent to each cataract surgery with insertion of an intraocular lens.” Coverage is only for therapy required because of an absent or malfunctioning body part that normally permits food to reach the digestive tract. 4 EN therapy is a means to provide nourishment directly to the digestive tract of a patient who cannot, for a variety of reasons, ingest an appropriate amount of calories to main-tain an acceptable nutrition status. For EN, the patient may have a functioning gastrointestinal tract but must be unable to maintain appropriate weight and strength because of pathology to, or the nonfunction of, the structures that nor-mally permit food to reach the digestive tract. Thus, under Medicare guidelines, enteral therapy would be reasonable for the following:  •  A beneficiary with a nonfunctioning gastroin-testinal tract who cannot maintain appropriate weight because of disease or nonfunction of the structures that normally permit food to reach the digestive tract  •  A beneficiary with a disease of the small bowel that precludes digestion and absorption of suf-ficient nutrients and necessitates tube feeding to maintain the appropriate weightMedicare generally covers PN in both home health and outpatient delivery settings. Medicare has issued a National Coverage Determination (NCD), which requires the patient to have a severe pathology of the alimentary tract that does not allow absorption of sufficient nutrients to maintain weight and strength commensurate with the patient’s general condition. 5  A period of hospitalization is required to initiate coverage for PN and to train the patient in how to prepare, manage, and administer the  88S  Journal of Parenteral and Enteral Nutrition /  Vol. 34, Suppl. 1, November 2010 formula and equipment. The NCD also requires a physi-cian’s written order or prescription and sufficient medical cumentation to show that the prosthetic device coverage requirements are met and that PN therapy is medically necessary. Before approving coverage, the Medicare Durable Medical Equipment Regional Contractor (DMERC) must agree that a particular condition quali-fies for PN therapy.EN and PN therapies are not covered under part B in situations involving temporary impairments. Coverage of such therapy, however, does not require a medical judg-ment that the impairment giving rise to the therapy will persist throughout the patient’s remaining years. If the medical record, including the judgment of the attending physician, indicates that the impairment will be of long and indefinite duration, the test of permanence is consid-ered met. Permanence is currently defined by Centers for Medicare & Medicaid Services (CMS) as a patient’s requir-ing EN or PN for >90 days. Once Medicare coverage standards are met, the program will generally cover—with  very few restrictions—all medically necessary formulas, administration supplies, and equipment associated with both parenteral and enteral nutrition.Section 1861(s)(2)(V) of the Act authorized Medicare part B coverage of medical nutrition therapy (MNT) serv-ices for certain beneficiaries who have diabetes or a renal disease, effective for services furnished on or after January 1, 2002. Building upon an Institute of Medicine (IOM) report, Medicare part B pays for MNT services provided by a registered dietitian (RD) or nutrition professional when the beneficiary is referred for the service by the treating physician. 6  Services covered consist of face-to-face nutrition assessments and interventions in accord-ance with nationally accepted dietary or nutrition protocols. 7  Because RDs and nutrition professionals are the only providers eligible for Medicare reimbursement for this service, MNT cannot be billed “incident to.” In addition, RDs and nutrition professionals must accept assignment for all Medicare services that they furnish, unlike physicians, for whom the acceptance of assign-ment is not mandatory. 8  Thus, MNT services can only be claimed by RDs who have their own National Provider Identifier (NPI) number and have assigned their benefits to the group that claims reimbursement (Table 1).The following Current Procedural Terminology (CPT) codes are specific for MNT services (CPT® is a registered trademark of the American Medical Association[AMA]):  • 97802—MNT initial assessment and interven-tion, individual, face-to-face with the patient, each 15 minutes  • 97803—MNT reassessment and intervention, individual, face-to-face with the patient, each 15 minutes  • 97804—MNT group, ≥ 2 individuals, each 30 minutes   Figure 1. Durable medical equipment Medicare administrative contractors.  The Future for Physician Practice in Nutrition /   Brill et al 89S   • G0270—MNT reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical con-dition, or treatment regimen, individual, face-to-face with the patient, each 15 minutes  • G0271—MNT reassessment and subsequent intervention(s) following second referral in same  year for change in diagnosis, medical condition, or treatment regimen, group, each 30 minutesBecause reimbursement for MNT services is low, most physicians bill for their efforts using the Evaluation + Management (E/M) codes. But at least they can bill; under Medicare, pharmacists are ineligible to bill for their cognitive efforts, despite numerous studies showing how their efforts can improve patient care and overall outcomes. 9 “Incident-to” services billed by physicians and non-physician practitioners are defined as those services that are furnished incident to physician professional services in the physician’s office (whether located in a separate office suite or within an institution) or in a patient’s home. These services are billed as part B services as if the physician personally provided them and are paid under the physician fee schedule.To qualify as “incident to,” services must be part of the patient’s normal course of treatment, during which a physician personally performs an initial service and remains actively involved in the course of treatment.  Although the physician does not have to be physically present in the patient’s treatment room while these serv-ices are provided, the physician must provide direct supervision and be present in the office suite to render assistance, if necessary. The patient record should docu-ment the essential requirements for incident-to service. 10 Section 1886(d) of the Act sets forth a system of pay-ment for the operating costs of acute care hospital inpa-tient stays under Medicare part A (Hospital Insurance) based on prospectively set rates. This payment system is referred to as the inpatient prospective payment system (IPPS). Under the IPPS, each case is categorized into a diagnosis-related group (DRG). Each DRG is assigned a payment weight assigned, based on the average resources used to treat Medicare patients in that DRG. If the hos-pital treats a high percentage of low-income patients, it receives a percentage add-on payment applied to the DRG-adjusted base payment rate. This add-on, known as the disproportionate share hospital (DSH) adjustment, provides for a percentage increase in Medicare payment for hospitals that qualify under either of 2 statutory for-mulas designed to identify hospitals that serve a dispro-portionate share of low-income patients. Also, if the hospital is an approved teaching hospital, it receives a percentage add-on payment for each case paid through IPPS. This add-on, known as the indirect medical educa-tion (IME) adjustment, varies depending on the ratio of residents to beds under the IPPS for operating costs and according to the ratio of residents to average daily census under the IPPS for capital costs. For particular cases that are unusually costly, known as outlier cases, the IPPS payment is increased. This additional payment is designed to protect the hospital from large financial losses due to unusually expensive cases. Any outlier payment due is added to the adjusted base payment rate, plus any DSH or IME adjustments. 11 Having established a mechanism to cover enteral and parenteral therapy, Medicare does not pay for health pro-fessionals (eg, pharmacists, nurses, dietitians [aside from covered MNT services]) under part A and limits payment for health professionals under part B. Medicare covers services provided by eligible professionals including phy-sicians, nurse practitioners and physician assistants, and medical nutrition services provided by an RD. Under parts A + B, Medicare does not separately pay for services provided by pharmacists or nurses. 12 Medicare pays a fee for each medical service. But the amount paid per service is only one of the components contributing to Medicare’s spending. Another factor is the number of beneficiaries. According to the Medicare trus-tees 2008 report, the number of Medicare beneficiaries will increase significantly between now and 2030, rising from 45.2 million to 79 million. 13 In addition to fees and growth in the number of ben-eficiaries, the average number and type (or “intensity”) of the services provided by physicians contribute to total Medicare physician spending. Taken together, the average number and type of physicians’ services constitute their “volume.” Medicare physician spending per beneficiary is thus equal to fees times the volume of services. Each year, Medicare sets fees for physicians’ services using formulas in the Medicare fee schedule for physicians’ services and the sustainable growth rate (SGR) mechanism. However, because Medicare does not control the volume of services that physicians provide, physician spending per benefici-ary can grow even if fees are reduced. Table 1.  Reimbursement for Medical Nutrition Therapy Services CodewRVUFacilityOffice978020.53$27.41$29.21978030.45$23.80$25.61978040.25$12.98$12.98G02700.37$20.92$22.72G02710.25$12.98$12.98wRVU, Work Relative Value Units
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