Billing Process – How to Create a CMS 1500 Claim
Learn how Healthie's insurance feature helps nutrition professionals streamline the billing process when creating a CMS 1500 claim.
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Creating, submitting, and monitoring CMS 1500 claims is a time-consuming task. For insurance-based dietitians, allocating the time needed for insurance billing takes away from client-facing time and other income-generating services.
Healthie’s insurance feature allows insurance-based providers to streamline their insurance billing directly through their EHR. With auto-fill CMS 1500 claims and easy claim submission, nutrition and wellness professionals can quickly generate and batch-send insurance claims. By optimizing back-end office time spent on billing, providers can increase client load, expand services, and increase profits for their insurance-based practices.
This article walks through how you can leverage Healthie to:
- Create CMS-1500 claims
- Collect client insurance information pre-session
- Track a client’s insurance authorization information, and coverage
- Charge clients for copay amounts, or non-covered services
- Run billing reports to stay up-to-date on your claims and reimbursement status
Getting Started with Healthie’s Insurance Billing Platform
As you onboard a new client to your practice that will be using insurance, it’s important to collect the right information. These details will be used to fill out an insurance claim post-session.
Client information to capture for insurance billing:
- Client’s contact information: including name, address, social security number
- Client’s insurance information
- Basic client demographics: including gender, height and weight (submitting claims using BMI-related codes is common in preventive care, and weight management)
- Provider (your) information: NPI, service location, In-Network Provider ID number and any other relevant information required by the insurance provider
- Diagnosis codes: include all appropriate CPT and ICD-10 codes
- Referring provider information: doctor’s name and NPI number (some insurance plans may require a referral from your client’s MD, if not you can leave this information blank on your CMS 1500 claim form)
Creating an intake form for insurance-based clients:
With Healthie’s Form Builder, you can easily create multiple different forms, and charting notes, to be used with your clients. There are even a host of pre-created forms for you to leverage, including and “Insurance Information” form and a “Billing Information,” form. The forms that you create can be assigned to an Intake Flow within Healthie, which is a series of electronic paperwork that your client will be prompted to fill out once you add them as a client to Healthie.
Watch this brief video to see how you can easily create an “intake flow” for your insurance clients, and leveraging these pre-created forms to easily capture your client’s insurance and billing information.
Creating a CMS 1500 Claim in Healthie
After you complete your chart note on your client, you can take several actions: either save the chart note, export it as a Superbill, or export it as a CMS 1500 claim. You can also access Healthie’s CMS 1500 creator by navigating to the “Billing” tab on your provider dashboard > CMS 1500.
For your convenience when creating insurance claims with Healthie, much of the information you’ve collected during the intake process will auto-fill on your form. After creating your first CMS 1500 form in Healthie, subsequent forms will also automatically pre-fill with information (like your provider information, or referring doctor info) to make ongoing claim submission run smoothly.
Most of this information you’ll have captured during your initial session, and will pre-populate into the form. Review this section to make sure that all fields are completed, including:
- Client Name (as shown on their insurance card)
- Date of birth
- Social security number
Referring Provider Information
Some insurance plans will require a referral from a physician in order for nutrition services to be reimbursed. When your client, or your office, calls to confirm your client’s coverage, you should inquire if a referral is needed. If so, either you or your client can request one directly from the MD.
Download a Sample Nutrition Counseling Referral Form that you can modify for your practice, and send it to your client’s doctor as needed. If you receive ongoing client referrals from a particular doctor or other healthcare providers, you can store their contact information with your Healthie account. As you create your CMS 1500 claims, you’ll be able to select the referring provider from a drop-down box while you’re creating the came, and all of their relevant information will pre-populate on the form.
You’ll need to obtain:
- Referring provider’s name and address
- Referring provider’s NPI number
- Select the Qualifier Code from the drop-down. The code most commonly used for a physician referring a client for nutritional counseling in a private practice setting will be Referring Provider – DN.
On the CMS 1500 Form, the service facility refers to the address where the nutrition services were provided. If you have multiple office locations for example, you’ll want to put the location where the session actually took place. When you enter a new address in the service facility field, Healthie will automatically save it and it will appear in the drop down next time you complete a claim. Choose from your list of facilities for consistent, and accurate billing.
The Place of Service (POS) is a two digit code used on Box #24B to indicate what type of location the services occurred in. You’ll be able to select from the drop-down the appropriate POS code.
A description of each code as provided by CMS:
- Office (11) – Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis.
- Home (12) – Location, other than a hospital or other facility, where the patient receives care in a private residence.
- Place of Employment/Worksite (18) – A location, not described by any other POS code, owned or operated by a public or private entity where the patient is employed, and where a health professional provides on-going or episodic occupational medical, therapeutic or rehabilitative services to the individual.
- Telehealth (02) – The location where health services and health related services are provided or received, through telecommunication technology. Please note, previously a Modifier Code was required for telehealth sessions. POS code 02 now replaces this when submitting insurance claims for telehealth sessions. You’ll no longer need to include a modifier code when billing for telehealth.
- Other POS (99) – Other place of service not identified above.
A full list of POS codes can be found here. If the code you need is not listed above, you can contact us firstname.lastname@example.org
Choosing your CPT and ICD-10 Codes
As you navigate through the CMS 1500 form, you’ll be prompted to select a diagnosis (or ICD) code for your claim. ICD codes, simply put, represent the symptoms that your client is seeking to treat. You’ll need to include at least one ICD code for reimbursement. For your convenience, the majority of the ICD-10 codes have been pre-filled into Healthie, and you can easily select your code from the drop down list in the diagnosis section.
Common ICD-10 codes you’ll see used in nutritional care:
- Z71.3 – Dietary counseling and surveillance (typically used for preventative services)
- E11. – Type 2 Diabetes
- E66.0 – Obese due to excess calories
- E66.3 – Overweight (weight management referrals)
CPT, or Current Procedural Terminology, codes are the codes that identify the service you provided as a healthcare professional. The three most common medical nutrition therapy (MNT) codes that dietitians use on claims are listed below. Public insurers, like Medicare and Medicaid, as well as private insurance carriers, can use these CPT codes.
- 97802 – For an initial assessment, face-to-face
- 97803 – For a follow up visit or reassessment, face-to-face
- 97804 – For a group visit (2 or more individuals)
When filling out a CMS 1500 form, you will also have to specify the number of units and your fee per unit. Insurance billing is in units of 15 minutes each (ie. a 1-hour initial assessment is 4 units).
It’s important to keep in mind that diagnosing clients is outside the scope of practice for dietitians. For best practices, it’s recommended to receive a referral from your client’s medical doctor listing their medical conditions or requesting a copy of your client’s chart/latest chart note from their doctor. Referrals and chart notes can be sent securely through E-Fax within the Healthie platform, and then saved as a document within your client’s Healthie chart. Obtaining this information and storing it within your EHR will back-up your billing claims in the case of an audit, and help protect you from any liability.
Next to CPT codes there are fields for a modifier code (which may not be necessary) and a diagnosis pointer field (which should be indicated). It is important to remember that the primary reason for the patient’s visit indicates the primary diagnosis code pointer that should be used on the claim. Diagnosis code pointers are used to indicate the appropriate order of importance in relation to the service being performed. The first pointer designates the primary diagnosis for the service line. Remaining diagnosis pointers indicate declining level of importance to service line.
Healthie’s insurance authorization tracker
Many insurance-based providers confirm insurance coverage for their client prior to their initial session by calling the insurance company directly. If a client is covered, you can ask for additional details, such as:
- Which billing codes your client will be covered for
- How many hours of nutritional counseling they are covered for (a billing unit for insurance companies is 15 minutes — so how many billing units annually will be reimbursed?)
- The authorization number (some plans may require pre-authorization prior to the initial session)
- Reference number for your call
Once you’ve obtained this authorization information, you’ll be able to enter into your clients Insurance Authorization Tracker within their client account. The tracker will automatically deduct sessions when a client books, and will show how many remaining sessions a client has within their benefits year. This information will allow you to quickly and efficiently stay on top of your client’s amount of remaining covered sessions.
Collecting client-owed amounts
Obtaining your client’s payment information is important for collecting client-owed responsibilities (ie. copays, deductibles, denied claims), enforcing cancellation policies, and charging for non-covered services.
Healthie enables you to securely collect and store your client’s credit card and/or HSA/FSA card information directly within your EHR. Fully integrated with Stripe, no additional payment processor is required to complete your billing transactions. Easily send your clients an invoice, or charge them directly for out-of-pocket fees.
Monitoring claim status with Healthie reports
Within your Healthie Reports tab, you’ll be able to run reports relevant to your CMS 1500 claims and business financials. Navigate to Billing > Your CMS 1500 Claims > Select the date range that you would like to run the report for. This will show you ALL created claims within that time period. Your report will be available to view in your Documents Tab > Generated Reports.
Easily keep track of your reports by creating a Documents folder titled CMS 1500 Reports. You can create sub-folders for each month or a date-range that works best for your workflow. By diligently running your reports and proactively reviewing them, you’ll be able to keep tabs on your claim status, reimbursement status and more.
Running an insurance-based nutrition practice can be a rewarding and profitable business. Healthie’s Insurance platform supports dietitians by minimizing time needed to create and monitor insurance claims, while also helping to ensure accurate claim submission to reduce claim rejections.
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