Internal Medicine Coding Alert

Internal medicine practices often employ dieticians and nutritionists to work with patients in establishing diets that comply with the physicians treatment and help improve and maintain the patients health. For example, patients with high blood pressure or heart disease must often follow strict diets low in fat and cholesterol. Diabetics often need nutritional counseling to understand how to manage their condition. However, most practices report that they are unable to receive adequate reimbursement for these services.

Since the nutritionist or dietician is working under the direction of the physician and in conjunction with the prescribed treatment, shouldnt these services be considered incident to the overall physician service and billed to third-party payers with an office/outpatient service E/M code under the internists physician identification number (PIN)?

Some practices are doing this and receiving reimbursement, but they face severe penalties in the event of an audit by Medicare, warns Barbara Cobuzzi, MBA, CPC, president of Physician Reimbursement Specialists, a physician group billing company based in Lakewood, N.J.

Billing incident to for these services depends on the payer. For Medicare it is illegal to report a code higher than 99211 for the services of a nutritionist or dietician, she says. Basically, for a non-physician provider to bill higher than a 99211, they have to be either a nurse practitioner, physician assistant, psychologist, clinical social worker or certified nurse-midwife. And, reimbursement for 99211 is completely inadequate for the services provided by the nutritionist, who often has to spend a significant amount of time with the patient.

Some Private Payers Do Pay

Some private insurers will assign dieticians and nutritionists their own PIN numbers and allow them to bill independently of the physician, says Cobuzzi. Other payers have instructed their participating physicians to bill the services incident to the physician service and reimburse at an acceptable level.

But, basically the professional societies representing these providers have not lobbied the Health Care Financing Administration (HCFA) to be included in the group of providers who can bill for services beyond those covered by 99211, she says.

Even to bill 99211 to Medicare, the dietician or nutritionist must be employed by the physician directly or involved in a Medicare-approved lease arrangement with the practice, adds Emily Hill, PA-C, president of Hill and Associates, a medical practice management and consulting firm in Southport, N.C.

If the dietician is not employed by the physician, they cannot bill Medicare at all, she says.

Billing the Patient

Cobuzzi advises telling patients that Medicare will not cover these services and getting them to pay separately, she says. I would inform the patient ahead of time that Medicare will not cover these services, she adds. Tell them, This is what the service costs and this is what it will do for you. And, I am really sorry that Medicare will not cover it. But, to bill it any other way would be breaking the law.

Note: Practices could get away with billing incident to and reporting a higher level E/M code. But, if the practice were audited, Medicare would discover that the services were not physician services and the practice could be found guilty of fraud.

Although the service is not covered and, therefore, a signed advance beneficiary notice (ABN) is not required, Cobuzzi recommends getting one anyway. You will want one so that the patient doesnt forget, get a bill, and then call the office, she says.

Use Counseling Codes

For reporting and tracking the dieticians services, Cobuzzi recommends using the CPT codes for counseling and/or risk factor reduction intervention (99401-99404). The codes are based on the amount of time the provider spends with the patient.

The codes can be reported to payers who allow the dietician to bill under his or her own PIN, or reported to Medicare with the -GA (waiver of liability statement on file) and -GX (service not covered by Medicare) modifiers.

I would go ahead and report the counseling codes with the modifiers applied, she explains. If you have an ABN signed, you need to report the code with the -GA modifier. The -GX modifier lets the carrier know that you know it wont be reimbursed, but you need a rejection to prove to the patient that Medicare wont pay for it.