What Are Fee Schedules & Reimbursement Rates?
Learn about insurance reimbursement for nutrition counseling and dietitians. Find out what fee schedules are and and why they're important.
Becoming an in-network nutrition provider with insurance payers is a strategic way to build a nutrition business. Patients can use their insurance to pay for nutrition counseling services, if included in their benefits plan. The in-network nutrition provider is then reimbursed by the insurance payers directly — with patients only being responsible for copays, deductibles or non-covered services if they apply.
Although this process sounds fairly straightforward, understanding insurance reimbursement is a complex process. The credentialing process itself can be a daunting endeavor. Being aware of important terminology and steps in the process will allow you to move through the credentialing process smoothly, and ensure the best reimbursement rates for your nutrition services.
Our guide to fee schedules as a dietitian becoming an in-network provider with insurance companies includes what a fee schedule is, why it is important, how to request one, common insurance billing codes, and what to look for on a fee schedule.
What are Fee Schedules?
A “fee schedule,” or contract rates, is a complete listing of fees used by insurance payers to pay doctors or other wellness providers/suppliers. Dietitians are considered “fee-for-service” providers, meaning that dietitians provide a service to clients and are then reimbursed later by insurance payers with an amount designated within their specific fee schedule.
Each insurance payer creates their own list of fees for all services rendered by wellness professionals — including the maximum amount reimbursed to fee-for-service providers, such as dietitians. For every insurance company that you credential with, there will be a different fee schedule. The only insurance payer that publicly lists their fee schedule is Medicare. For all other insurance payers, contract rates are private and unique to a healthcare provider.
When Do I Receive a Fee Schedule?
During the contracting process with insurance, the insurance payer will send a contract to the dietitian to sign. This contract outlines the terms, conditions and fees that the dietitian agrees to once they become credentialed as an in-network provider. Contracts do not always explicitly show the reimbursement rate (fees) — essentially the amount that you are agreeing to receive. This financial information is listed on the fee schedule, and you will most likely have to ask for it. In some cases, the fee schedule is provided but does not list any nutritionally-relevant codes, or the common ICD-10 codes that you will bill for.
If this is the case, then you can ask specifically what the contract rates are for your top billing codes. There may be an option to look up the codes within the health insurance company’s online portal for in-network providers, or you can request the fee schedule/contract rates for specific codes from your Network Coordinator.
If you sign the contract without seeing the fee schedule, then you are essentially agreeing to a contract rate determined by the insurance payer. You’ll lose the opportunity to negotiate your reimbursement rates. Although it may be quicker (and easier) to sign the contract fees unseen, your services as a nutrition professional are valuable – and your reimbursement amounts should reflect this. Some insurance payers may be open to negotiating your contract rates, while others may state that fees are non-negotiable.
Which Insurance Billing Codes Should I Look for on the Fee Schedule?
As the fee schedule is a list of fees for all services and procedures, it can be difficult to discern which ones apply to nutrition services. When billing insurance payers, you’ll indicate a billing code on your CMS1500 claim for each client encounter (under billing items). What you need to know from the fee schedule, is the fee/reimbursement rate for the billing code that you’ll actually be submitting. Billing codes often apply to specific unit of time, such as 15 minutes, with the ability to bill for multiple units.
Here are commonly used insurance billing codes by dietitians and nutrition professionals. Keep in mind that not all insurance payers will reimburse for these codes. This list can be used as a reference when requesting the fee schedule from an insurance payer that you are contracting with.
CPT® Codes for Nutrition Services
Current Procedural Terminology are set by the American Medical Association, and offer doctors and healthcare professionals a uniform language for coding medical services and procedures. AMA’s evidenced-based CPT codes have generally been adopted across Insurance Payers, to streamline reporting, increase accuracy and efficiency.
All CPT codes are five-digits and can be either numeric or alphanumeric, depending on the category. CPT code descriptors are clinically focused and utilize common standards so that a diverse set of users can have a common understanding across the clinical healthcare paradigm.
Note: The CPT code describes what was done during the patient consultation, including diagnostic and medical procedures, while the ICD code identifies a diagnosis and describes a disease or medical condition. You’ll list the ICD code separately on the CMS1500 claim. Do not confuse CPT codes with ICD codes!
97802 – medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient; each 15 minutes
97803 – medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient; each 15 minutes
97804 – medical nutrition therapy; group (2 or more individuals); each 30 minutes
CPT codes 97802 and 97803 should be unit priced; four units = 60 minutes, and six units = 90 minutes
S9470 – nutrition counseling, dietitian visit
98966 – telephone evaluation and management service provided by a qualified nonphysician healthcare provider, 5-10 minutes
98967 – telephone evaluation and management service provided by a qualified nonphysician healthcare provider, 11-20 minutes
98968 – telephone evaluation and management service provided by a qualified nonphysician healthcare provider, 21-30 minutes
99402 – preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 30 minutes
99403 – preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 45 minutes
99404 – preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 60 minutes
99411 – preventive medicine counseling and/or risk factor reduction intervention(s) provided in a group setting; approximately 30 minutes
99412 – preventive medicine counseling and/or risk factor reduction intervention(s) provided in a group setting; approximately 60 minutes
99443 – telephone evaluation and management service by a physician or other qualified healthcare professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion
HCPCS Codes for Nutrition Services
Healthcare Common Procedure Coding System is a collection of codes that represent procedures, supplies, products and services which may be provided to Medicare beneficiaries and to individuals enrolled in private health insurance programs. HCPCS codes are used for billing Medicare and Medicaid patients:
G0270 – medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regiment (including additional hours needed for renal disease), individual, face-to-face with the patient; each 15 minutes
G0271 – medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regiment (including additional hours needed for renal disease), group (2 or more individuals), each 30 minutes)
G0108 – DSMT (diabetes self-management training), individual session, each 30 minutes
G0109 – DSMT (diabetes self-management training), group session (2 or more individuals), each 30 minutes
G0447 – behavioral counseling for obesity, individual, face-to-face behavioral counseling for patients with a BMI ≥ 30, who are alert and able to participate in counseling.
Insurance Payer Contract Traps to Look Out For
Some insurance payers reimburse based on a percentage of the Medicare fee schedule, as opposed to a set $ amount per time. Before signing your contract, and agreeing to the fee terms, be sure to confirm if fees are set or based on a percentage rate. If they are indeed a percentage, you’ll want to negotiate that you are reimbursed at 100% (or more), as Medicare reimbursement rates are generally low.
Have your fee schedule? Learn how to effectively negotiate your contract rate as a dietitian with insurance payers here.
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