Registered dietitians' coding practices and patterns of code use

Coding, coverage, and reimbursement are vital to the clinical segment of our profession. The objective of this study was to assess understanding and use of the medical nutrition therapy (MNT) procedure codes. Its design was a targeted, cross-sectional, Internet survey. Participants were registered dietitians (RDs) preselected based on Medicare Part B provider status, randomly selected RDs from the American Dietetic Association database based on clinical practice designation, and self-selected RDs. Parameters assessed were knowledge and use of existing MNT and/or alternative procedure codes, barriers to code use/compensation, need for additional codes for existing/emerging services, and practice demographics. Results suggest that MNT is being reimbursed for a variety of diseases and conditions. Many RDs working in clinic settings are undereducated about code use of any kind, reporting that code selection frequently is determined not by the RD providing the service, but by "someone else." Self-employed RDs are less likely to rely on others to administrate paperwork required for reimbursement, including selection of procedure codes for billable nutrition services. Self-employed RDs are more likely to be reimbursed by private or commercial payers and RDs working in clinic settings are more likely to be reimbursed by Medicare; however, the proportion of Medicare providers in both groups is high. RDs must be knowledgeable and accountable for both the business and clinical side of their nutrition practices; using correct codes and following payers' claims processing policies and procedures. This survey and analysis is a first step in understanding the complex web of relationships between clinical practice, MNT code use, and reimbursement.     

The estimated costs and savings of medical nutrition therapy: the Medicare population

OBJECTIVES: To measure the potential savings from medical nutrition therapy (MNT) and to estimate the net cost to Medicare of covering these services for Medicare enrollees. This includes developing an estimate of the cost of providing medical nutrition services to the Medicare population and estimating the savings in hospital and other spending resulting from the use of these services. DESIGN: Analysis of longitudinal data from the Group Health Cooperative of Puget Sound (Seattle, Wash) for persons aged 55 years and older who have coverage for MNT services. SUBJECTS/SETTING: Persons aged 55 years and older who had diabetes (n = 12,308), cardiovascular disease (n = 10,895), or renal disease (n = 3,328) and who were covered under the Group Health Cooperative of Puget Sound, including Medicare beneficiaries enrolled in the plan's Medicare risk contract program. Extrapolation to the US Medicare population is based on data for persons served by the Group Health Cooperative of Puget Sound. INTERVENTION: The use of MNT. MAIN OUTCOMES MEASURE: Differences in health care utilization levels of persons with diabetes, cardiovascular disease, and renal disease who do and do not receive MNT. Differences in utilization were estimated for hospital discharges per calendar quarter, physician visits per quarter, and other outpatient visits per quarter. STATISTICAL ANALYSES PERFORMED: Multivariate regression models of changes in utilization for persons after they receive MNT services. RESULTS: Our analysis showed that MNT was associated with a reduction in utilization of hospital services of 9.5% for patients with diabetes and 8.6% for patients with cardiovascular disease. Also, utilization of physician services declined by 23.5% for MNT users with diabetes and 16.9% for MNT users with cardiovascular disease. The net cost of covering MNT under Medicare is estimated to be $369.7 million over the 1998 through 2004 period. The total cost of benefits is estimated to be $2.7 billion over this period. This would be partially offset by estimated savings of $2.3 billion resulting in net costs of $369.7 million. The program would actually yield net savings after the third year of the program, which would continue through 2004 and beyond. CONCLUSION: After an initial period of implementation, coverage for MNT can result in a net reduction in health services utilization and costs for at least some populations. In the case of persons aged 55 years and older, the savings in utilization of hospital and other services will actually exceed the cost of providing the MNT benefit. These results suggest that Medicare coverage of MNT has the potential to pay for itself with savings in utilization for other services.     

Position of the Academy of Nutrition and Dietetics: The Role of Medical Nutrition Therapy and Registered Dietitian Nutritionists in the Prevention and Treatment of Prediabetes and Type 2 Diabetes

It is the position of the Academy of Nutrition and Dietetics that for adults with prediabetes or type 2 diabetes, medical nutrition therapy (MNT) provided by registered dietitian nutritionists (RDNs) is effective in improving medical outcomes and quality of life, and is cost-effective. MNT provided by RDNs is also successful and essential to preventing progression of prediabetes and obesity to type 2 diabetes. It is essential that MNT provided by RDNs be integrated into health care systems and public health programs and be adequately reimbursed. The Academy’s evidence-based nutrition practice guidelines for the prevention of diabetes and the management of diabetes document strong evidence supporting the clinical effectiveness of MNT provided by RDNs. Cost-effectiveness has also been documented. The nutrition practice guidelines recommend that as part of evidence-based health care, providers caring for individuals with prediabetes or type 2 diabetes should be referred to an RDN for individualized MNT upon diagnosis and at regular intervals throughout the lifespan as part of their treatment regimen. Standards of care for three levels of diabetes practice have been published by the Diabetes Care and Education Practice Group. RDNs are also qualified to provide additional services beyond MNT in diabetes care and management. Unfortunately, barriers to accessing RDN services exist. Reimbursement for services is essential. Major medical and health organizations have provided support for the essential role of MNT and RDNs for the prevention and treatment of type 2 diabetes.     

Position of the American Dietetic Association: Integration of Medical Nutrition Therapy and Pharmacotherapy

It is the position of the American Dietetic Association that medical nutrition therapy (MNT), as a part of the Nutrition Care Process, should be the initial step and an integral component of medical treatment for management of specific disease states and conditions. If optimal control cannot be achieved with MNT alone and concurrent pharmacotherapy is required, the Association promotes a team approach and encourages active collaboration among registered dietitians (RDs) and other health care team members. RDs use MNT as a cost-effective means to achieve significant health benefits by preventing or altering the course of diabetes, obesity, hypertension, disorders of lipid metabolism, heart failure, osteoporosis, celiac disease, and chronic kidney disease, among other diseases. Should pharmacotherapy be needed to control these diseases, a team approach in which an RD brings expertise in food and nutrition and a pharmacist brings expertise in medications is essential. RDs and pharmacists share the goals of maintaining food and nutrient intake, nutritional status, and medication effectiveness while avoiding adverse food-medication interactions. RDs manipulate food and nutrient intake in medication regimens based on clinical significance of the interaction, medication dosage and duration, and recognition of potential adverse effects related to pharmacotherapy. RDs who provide MNT using enhanced patient education skills and pharmacotherapy knowledge are critical for successful outcomes and patient safety.     

Position of the American Dietetic Association: nutrition services in managed care

It is the position of the American Dietetic Association that medical nutrition therapy is an essential component of disease management and healthcare provided by managed care organizations, and that such care must be provided by qualified nutrition professionals. Compared with traditional fee-for-service reimbursement systems, managed care presents new opportunities for dietetics professionals. Until recently, the lack of billing infrastructure has handicapped nutrition providers who wish to bill for their services and has made it difficult to track the outcomes of nutrition care. With the publication of current procedure terminology codes for medical nutrition therapy (MNT) and the implementation of MNT benefits in Medicare part B for diabetes and nondialysis kidney disease, commercial payers, including managed care organizations (MCOs) are likely to implement or expand their coverage of MNT. A large body of evidence supports the efficacy and cost-effectiveness of MNT coverage within managed care plans. This evidence includes cost analyses of conditions treated by MNT, and clinical trial data confirming the efficacy of MNT in improving patient outcomes. MNT is also an important part of national standards of care for many chronic disease conditions. Based on evidence supporting the role of MNT in improving patient outcomes, the Institute of Medicine (IOM) recommended that MNT services be reimbursed by Medicare when patients are referred by a physician. Provision of appropriate MNT can also help MCOs meet accreditation and quality standards established by entities such as the National Committee for Quality Assurance and the Joint Commission for the Accreditation of Health Care Organizations. Much of the work required to secure a place for MNT in MCOs will be done at the practitioner level, by nutrition professionals themselves. Registered dietitians must market MNT to their customers in managed care by addressing the needs of each player. By emphasizing the importance of MNT and other cost-effective forms of preventive care and disease management, MCOs will be well positioned to improve population health at modest cost.     

Diabetes self-management training program in a community clinic improves patient outcomes at modest cost

Stringent glycemic control reduces complications and health care costs for people with diabetes. This study assessed the effectiveness of a diabetes self-management training (DSMT) program at a community clinic. Education and a glucometer were provided to 70 people with type 2 diabetes in a 4-hour class, followed by individual dietitian consults and monthly support meetings. Most participants were Hispanic or African American with mean age of 49+/-10 years and mean body mass index of 34+/-9. Body weight, glycosylated hemoglobin (A1C), medications, and follow-up attendance were monitored. After 2 to 12 months of program participation, mean A1C improved from 9.7+/-2.4% to 8.2+/-2.0% (P<.001); 61% experienced positive medication outcomes. The cost of community clinic DSMT was approximately $280 per person per year, $185 for each point reduction in A1C. This study indicated that community clinic DSMT can improve glycemic control at modest cost.     

Improving quality of care using a diabetes registry and disease management services in an integrated delivery network.

Disease management for chronic conditions is a call for collaboration among all parties of the health care system. The Caritas Christi Health Care System established a unified American Diabetes Association (ADA) recognized outpatient diabetes self-management education program (DSME) in each of its six hospital communities and has established an Internet data portal with managed care organizations to improve preventive care for thousands of patients with diabetes. This article describes the stepwise process of building the successful Caritas Diabetes Care Program and the central role of the Caritas Diabetes Registry over a 5-year period.     

Medical Nutrition Therapy for Adults in Health Resources & Services Administration-Funded Health Centers: A Call to Action

Vulnerable adult populations’ access to cost-effective medical nutrition therapy (MNT) for improving outcomes in chronic disease is poor or unquantifiable in most Health Resources & Services Association (HRSA)-funded health centers. Nearly 50% of the patients served at Federally Qualified Health Centers are enrolled in Medicaid; the lack of benefits and coverage for MNT is a barrier to care. Because the delivery of MNT provided by registered dietitian nutritionists is largely uncompensated, health centers are less likely to offer these evidence-based services and strengthen team-based care. The expected outcomes of MNT for adults with diabetes, obesity, hypertension, and other conditions align with the intent of several clinical quality measures of the Uniform Data System and quality improvement goals of multiple stakeholders. HRSA should designate MNT as an expanded service in primary care, require reporting of MNT and registered dietitian nutritionists in utilization and staffing data, and evaluate outcomes. Modification to the Centers for Medicare & Medicaid Services Prospective Payment System rules are needed to put patients over paperwork: HRSA health centers should be compensated for MNT provided on the same day as other qualifying visits. Facilitating the routine delivery of care by qualified providers will require coordinated action by multiple stakeholders. State Medicaid programs, Medicaid Managed Care Organizations, and other payers should expand benefits and coverage of MNT for chronic conditions, factor the cost of providing MNT into adequate and predictable payment streams and payment models, and consider these actions as part of an overall strategy for achieving value-based care.     

Shortcomings in public and private insurance coverage of diabetes self-management education and support

The objective of this study is to present preliminary data to characterize public and private insurance coverage for diabetes self-management education (DSM Education) and diabetes self-management support (DSM Support). Representatives from Medicaid and 2 private insurance providers in 10 states provided coverage information for their insurance plans. Two states (the most populous state from the East and West coasts) were sampled purposively and 8 additional states from 4 geographic regions (northeast, southeast, northwest, southwest) were sampled at random. Representatives from each private insurer described both a premium and basic coverage plan. Thus, 10 Medicaid programs and 40 private insurance plans were represented. Information about Medicare coverage was accessed from publicly available documents. Restricted by physician certification of patient eligibility, Medicare coverage included 10 hours of DSM Education plus 3 hours of medical nutrition therapy (MNT) within a continuous 12-month period, and 4 hours of follow-up (2 hours DSM Education and 2 hours MNT) for each subsequent year. Only 22 of 40 sampled private insurance and 5 of 10 Medicaid plans covered DSM Education, which ranged from 7 to 20 hours of education per year. Medicaid and private plans often limited the amount of DSM Education or required patients to obtain a physician certification of eligibility. Other than on-demand access features, coverage of DSM Support was minimal. Public and private insurance coverage of DSM Education was neither widespread nor uniform, while coverage of DSM Support was scarce.     

Delivering Diabetes Self-Management Education (DSME) in Primary Care

Background

Diabetes self-management education (DSME) is a critical component of the clinical management of diabetes mellitus. Although DSME is recognized as important, the number of patients with diabetes who receive education is disproportionately small. Several barriers to receiving diabetes education exist, including access and DSME delivery approaches.

Objective

The purpose of this project was to explore opportunities to meet the Healthy People 2010 goal of increasing the proportion of people with diabetes mellitus who receive diabetes education from 40% (as it was in 1998) to 60% (in 2010). Our objectives were to examine the provision of DSME in primary care, to determine if DSME delivery in primary care increases the number of people who receive DSME, and to evaluate the effect of DSME on glycosylated hemoglobin (HbA_1c) and low-density lipoprotein-cholesterol (LDL-C) levels. DSME was delivered in primary care practices as part of the Pittsburgh Regional Initiative for Diabetes Education (PRIDE).

Research design and methods

A nurse who was a certified diabetes educator (CDE) was deployed to provide Point-Of-Service diabetes Education (POSE) to four University of Pittsburgh Medical Center (UPMC) Community Medicine Practices (CMI) primary care practices. The group of patients who received POSE was compared with patients from the same practices who were identified as having diabetes and who received usual care. The number of patients was computed and a percentage calculated for comparison against Healthy People 2010 goals. The HbA_1c values of patients were tracked from January 2003 through December 2006, during the timeframe that POSE was provided.

Results

Of the 5344 diabetes patients in the four practices, 784 received POSE. Mean HbA_1c values were higher at baseline in those patients who received POSE than those who received usual care. There was a significant decrease in HbA^1c and LDL-C levels in both groups. Although there was not a significant between-group difference in HbA^1c, those who received POSE had significant improvement in LDL-C levels compared with the usual care group.

Conclusions

Providing DSME in primary care is feasible and offers the opportunity to reach patients who may not be receiving DSME services. However, further research is needed to evaluate other methodologies to increase access to DSME and other factors that may influence improvement in clinical outcomes.

     

Impact of municipal health services Medicare waiver program.

A major goal of the municipal health services program (MHSP) was improvement of health services for the elderly while containing Medicare reimbursement. A Health Care Financing Administration financed Medicare waiver program provided some additional benefits to Medicare Part B enrollees who used the MHSP clinics. Disadvantaged and sicker elderly groups were underrepresented in MHSP facilities. However, even after taking these differences between MHSP and other patients into account, analyses of Medicare records showed that participants in this program had lower reimbursement for hospital inpatient, outpatient, and emergency room services. Also, participants had higher reimbursements for physicians' ambulatory and ancillary care. The net result was total Medicare reimbursements were decreased for program participants.     

Effects of the Medicare Alzheimer's disease demonstration on Medicare expenditures

Applicants were randomized either into a group with a limited Medicare community care service benefit and case management or into a control group receiving their regular medical care. Analyses assess whether or not community care management affected health care use. A tendency toward reduced expenditures was observed for the treatment group, combining all demonstration sites, and when observing each separately. These differences were or approached statistical significance in two sites for Medicare Part A and Parts A and B expenditures averaged over 3 years. Expenditure reductions approached budget neutrality with program costs in two sites.     

Diabetes Self-Management Education Research

An international literature search was conducted to identify studies published since 1995 examining the effects of diabetes self-management education (DSME) in community settings. Of the 24 publications identified, eight were examined to provide a discussion of intervention methods, the use by study authors of behavioral theories and models to explain cognitive and psychosocial processes, the employment of community partnerships and collaborations to enhance patient and community ownership of DSME, and the effects of DSME on intermediate- and short-term outcomes. Reported intermediate outcomes established that researchers are now beginning to recognize the complexity of diabetes.Interventions across publications included the use of lay health educators, family members in learning sessions, exercise classes in the community, support groups, and cooking demonstrations. Only two of eight studies identified a behavioral theory to explain cognitive and psychosocial processes. The lead agencies in all eight studies were medical universities or diabetes clinics that worked closely with community partners to deliver DSME in community settings. Community partners included diabetes centers, local churches, residential centers, and work sites. Studies in this review examined the effect of DSME on intermediate outcomes that included exercise, self-care behaviors, dietary habits, clinical service usage, self-esteem, social support, diabetes knowledge, and health beliefs, with one or more studies finding improvements in dietary habits, exercise, and diabetes knowledge. Short-term outcomes such as fasting glucose, glycosylated hemoglobin (HbA_1c), body mass index, weight, blood pressure, total cholesterol, triglycerides, and impaired glucose tolerance were also examined.In at least one study, DSME favorably affected HbA_1c, cholesterol, body mass index, blood pressure, and fasting glucose. Studies discussed in this review demonstrated the effectiveness of a single DMSE intervention delivered in community settings. DSME has proven effective in improving both intermediate- and short-term outcomes. This review also revealed opportunities to improve the effectiveness of DSME studies in community settings.Future DSME studies should give more attention to identifying appropriate behavioral theories or models that help explain the mediating effects of cognitive and psychological processes on diabetes self-management. DSME studies in the future should continue to improve study designs to strengthen the credibility of research findings, use both qualitative and quantitative methods to capture intervention effects; and engage community members and partners in developing, implementing, and evaluating DSME interventions.     

Medicare Part B reimbursement and the perceived quality of physician care

The maximum amount physicians can charge Medicare patients for Part B services depends on Medicare reimbursement rates and on federal and state restrictions regarding balance billing. This study evaluates whether Part B payment rates, state restrictions on balance billing beyond the federal limit, and physician balance billing influence how beneficiaries rate the quality of their doctor’s care. Using nationally representative data from the 2001 to 2003 Medicare Current Beneficiary Survey, this paper finds strong evidence that Medicare reimbursement rates, and state balance billing restrictions influence a wide range of perceived care quality measures. Lower Medicare reimbursement and restrictions on physicians’ ability to balance bill significantly reduce the perceived quality of care under Part B.     

The State of Diabetes Care Provided to Medicare Beneficiaries Living in Rural America

CONTEXT: Diabetes poses a growing health burden in the United States, but much of the research to date has been at the state and local level. PURPOSE: To present a national profile of diabetes care provided to Medicare beneficiaries living in urban, semirural, and rural communities. METHODS: Medicare beneficiaries with diabetes aged 18-75 were identified from Part A and Part B claims data from 1999 to 2001. A composite of 3 diabetes care indicators was assessed (annual hemoglobin A1c test, biennial lipid profile, and biennial eye examination). FINDINGS: Over 77% had a hemoglobin A1c test, 74% a lipid profile, and 69% an eye examination. Patterns of care were considerably different across the urban-rural continuum at the state, Census division, and regional levels. States in the northern and eastern portions of the country had higher indicator rates for rural than for urban residents. States in the South had much lower rates for rural residents than their urban counterparts. Despite these within-state differences, across-state comparisons found that several states tended to have low indicator rates in every level of the urban-rural continuum. A common feature of these states was the relatively high concentration of nonwhite beneficiaries. For example, southern states had much higher concentrations of nonwhite beneficiaries relative to other areas in the country and demonstrated low rates in every level of the urban-rural continuum. CONCLUSIONS: Urban-rural quality of care differences may be a function not just of geography but also of the presence of a large nonwhite population.     

An economic history of Medicare part C

Context: Twenty‐five years ago, private insurance plans were introduced into the Medicare program with the stated dual aims of (1) giving beneficiaries a choice of health insurance plans beyond the fee‐for‐service Medicare program and (2) transferring to the Medicare program the efficiencies and cost savings achieved by managed care in the private sector. Methods: In this article we review the economic history of Medicare Part C, known today as Medicare Advantage, focusing on the impact of major changes in the program's structure and of plan payment methods on trends in the availability of private plans, plan enrollment, and Medicare spending. Additionally, we compare the experience of Medicare Advantage and of employer‐sponsored health insurance with managed care over the same time period. Findings: Beneficiaries’ access to private plans has been inconsistent over the program's history, with higher plan payments resulting in greater choice and enrollment and vice versa. But Medicare Advantage generally has cost more than the traditional Medicare program, an overpayment that has increased in recent years. Conclusions: Major changes in Medicare Advantage's payment rules are needed in order to simultaneously encourage the participation of private plans, the provision of high‐quality care, and to save Medicare money.     

Transcultural Diabetes Nutrition Algorithm (tDNA): Venezuelan Application

Medical nutrition therapy (MNT) is a necessary component of comprehensive type 2 diabetes (T2D) management, but optimal outcomes require culturally-sensitive implementation. Accordingly, international experts created an evidence-based transcultural diabetes nutrition algorithm (tDNA) to improve understanding of MNT and to foster portability of current guidelines to various dysglycemic populations worldwide. This report details the development of tDNA-Venezuelan via analysis of region-specific cardiovascular disease (CVD) risk factors, lifestyles, anthropometrics, and resultant tDNA algorithmic modifications. Specific recommendations include: screening for prediabetes (for biochemical monitoring and lifestyle counseling); detecting obesity using Latin American cutoffs for waist circumference and Venezuelan cutoffs for BMI; prescribing MNT to people with prediabetes, T2D, or high CVD risk; specifying control goals in prediabetes and T2D; and describing regional differences in prevalence of CVD risk and lifestyle. Venezuelan deliberations involved evaluating typical food-based eating patterns, correcting improper dietary habits through adaptation of the Mediterranean diet with local foods, developing local recommendations for physical activity, avoiding stigmatizing obesity as a cosmetic problem, avoiding misuse of insulin and metformin, circumscribing bariatric surgery to appropriate indications, and using integrated health service networks to implement tDNA. Finally, further research, national surveys, and validation protocols focusing on CVD risk reduction in Venezuelan populations are necessary.