If you are thinking about signing up to be a Medicare provider, there are some things to know. This article will boil down some of the most confusing terms, like “par”, “non-par”, “assignment”, and “relative value units”. We’ll cover the limits on what Medicare covers, how you can code it, and where you can provide services. But among the most important is whether Medicare rates will be enough to cover basic business expenses like rent. Read on to find out whether you want to fill out that Medicare Provider Enrollment Form, and the logistical hurdles you’ll encounter if you do.
What Diagnoses Will Medicare Cover?
Medicare only covers Medical Nutrition Therapy (MNT) services for beneficiaries with certain specific diagnoses. These covered diagnoses typically include:
- Diabetes: Both Type 1 and Type 2 diabetes are generally covered, reflecting the critical role that diet can play in managing blood sugar levels.
- Kidney Disease: This typically includes patients with non-dialysis kidney disease in stages 3-5. MNT can be essential in managing diet to support kidney function.
- Post-Kidney Transplant: MNT may also be covered for a certain period following a successful kidney transplant.
That’s it. The thing is that the limitations are hard to get across to your referring providers. This creates a situation where they’ll send referrals for obesity and malnutrition for which these clients have no coverage. This burns up time on your end, but it also affects referrals in subtle ways that aren’t obvious. Namely, the frustration factor for medical providers may affect how willing they are to consider making a dietitian referral at all.
What CPT Codes Does Medicare Consider?
For Medical Nutrition Therapy (MNT) services provided by dietitians, Medicare generally recognizes the following Current Procedural Terminology (CPT) codes:
- 97802: Medical Nutrition Therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes.
- 97803: Re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes.
- 97804: Group (two or more individuals), each 30 minutes.
How To Look Up The Physician’s Fee Schedule
Step one in the Medicare journey is to establish whether revenue will cover expenses given Medicare’s rates.
Many dietitians find that Medicare rates are not sufficient to support basic business expenses. To look up the rates paid in your area, go to the Physician Fee Schedule. Medicare only recognizes 97802, 97803, and the corresponding group codes.
Relative Value Units: Dietitians Are Paid ??15% Less Than The Physician Fee Schedule
RVUs translate into different reimbursement levels for different types of healthcare providers. Dietitians are generally reimbursed at ??85% of the physician fee schedule for services, meaning that for a service with an established payment rate for physicians, the dietitian would receive 85% of that amount.
So, you might be asking why all the question marks. It’s because the answer was buried so deep in the spreadsheets that it just couldn’t be verified. It appears to depend on your location. Please log in and leave a comment if you know the answer.
For a time during the pandemic, telehealth was covered under Medicare. Those days are ended, so we’re back in the office, with all the required business expenses offices bring.
For independent dietitians providing Medical Nutrition Therapy (MNT) services to Medicare beneficiaries, reimbursement is available for services provided in these places:
- Private Nutrition Offices
- Outpatient Clinics: Independent dietitians may offer services in outpatient medical clinics, working in collaboration with other healthcare providers.
- Home Health: Independent dietitians may provide MNT services in the patient’s home.
“Par” and “Non-Par”
Medicare, the U.S. federal health insurance program for people aged 65 and older, divides healthcare providers into two main categories: Participating Providers (Par) and Non-Participating Providers (Non-Par). Think of these classifications as being synonymous with “accepting assignment” and “not accepting assignment”.
- Participating Providers (Par): Participating providers have signed an agreement with Medicare to accept the Medicare-approved amount as full payment for covered services. This agreement is essentially an agreement to “accept assignment” for all Medicare services provided.
- Accepting Assignment: When a provider accepts assignment, they agree to charge only the Medicare-approved amount for a service. Medicare pays Dietitians 100% of this amount, for patients with Diabetes or Stage 3, 4, or 5 Kidney Disease. No other diagnosis is covered, and you basically get 2 hours per year (with some minor exceptions).
- Non-Participating Providers (Non-Par): Non-Participating providers can choose to accept or not accept assignment on a case-by-case basis.
- Not Accepting Assignment: When a Non-Par provider does not accept assignment, they can charge 15% more than the Medicare-approved amount. There is a limit called the “limiting charge,” which is typically 15% more than the Medicare-approved amount and this can be charged to the patient.
Being a Participating Provider (Par) in Medicare is synonymous with accepting assignment, and this has important implications not only for Medicare billing but also for billing secondary insurance.
The “Limiting Charge” Rule
Medicare Rate (minus the “relative value unit rate) + 15% Is The Max –And It’s Illegal to Charge The Patient More
There is a rule that limits the amount Non-Participating Providers can charge Medicare beneficiaries, known as the “limiting charge.” This rule applies whether or not the patient has secondary insurance.
The limiting charge is typically 15% more than the Medicare-approved amount for the service (though this can vary by state). Here’s how it works:
- Medicare-Approved Amount: This is the amount that Medicare has determined is “reasonable” for a particular service. Participating Providers accept this as full payment, while Non-Participating Providers may charge up to the limiting charge of Medicare’s Rate + 15%.
- Limiting Charge: For Non-Participating Providers who do not accept assignment, they can charge patients up to 15% more than the Medicare-approved amount. This means they are not accepting the Medicare-approved amount as full payment and are charging the patient up to 15% more.
So, Medicare Non-Participating Providers can charge up to 15% more than the Medicare-approved amount, known as the limiting charge, regardless of whether the patient has secondary insurance.
To Sum It Up
So as you wade into the weeds of considering becoming a Medicare Provider, we hope these details have helped clear up some of the vague concepts and saved you a few hours of time on CMS.gov and on the phone with Medicare representatives, great human beings who seem to answer every question except the one you’re asking.