Current Coding Practices and Patterns of Code Use of Registered Dietitian Nutritionists: The Academy of Nutrition and Dietetics 2013 Coding Survey

FROM THE ACADEMY

Current Coding Practices and Patterns of Code Use of Registered Dietitian Nutritionists: The Academy of Nutrition and Dietetics 2013 Coding Survey J. Scott Parrott, PhD; Jane V. White, PhD, RD, LDN, FADA, FAND; Marsha Schofield, MS, RD, LDN, FAND; Rosa K. Hand, MS, RDN, LD; Mary B. Gregoire, PhD, RD; Keith T. Ayoob, EdD, RD, CD/N, FAND; Jessie Pavlinac, MS, RD, CSR, LD; Jaime Lynn Lewis, RD, LDN; Karen Smith, MS, MBA, RD, LD, FADA ABSTRACT Coding, coverage, and reimbursement for nutrition services are vital to the dietetics profession, particularly to registered dietitian nutritionists (RDNs) who provide clinical care. The objective of this study was to assess RDN understanding and use of the medical nutrition therapy (MNT) procedure codes in the delivery of nutrition services. Its design was an Internet survey of all RDNs listed in the Academy of Nutrition and Dietetics (Academy)/Commission on Dietetics Registration database as of September 2013 who resided in the United States and were not retired. Prior coding and coverage surveys provided a basis for survey development. Parameters assessed included knowledge and use of existing MNT and/or alternative procedure codes, barriers to code use, payer reimbursement patterns, complexity of the patient population served, time spent in the delivery of initial and subsequent care, and practice demographics and management. Results show that a majority of respondents were employed by another and provided outpatient MNT services on a part-time basis. MNT codes were used for the provision of individual services, with minimal use of the MNT codes for group services and subsequent care. The typical patient carries two or more diagnoses. The majority of RDNs uses internal billing departments and support staff in their practices. The payer mix is predominantly Medicare and private/commercial insurance. Managers and manager/providers were more likely than providers to carry malpractice insurance. Results point to the need for further education regarding the full spectrum of Current Procedural Terminology codes available for RDN use and the business side of ambulatory MNT practice, including the need to carry malpractice insurance. This survey is part of continuing Academy efforts to understand the complex web of relationships among clinical practice, coverage, MNT code use, and reimbursement so as to further support nutrition services codes revision and/or expansion. J Acad Nutr Diet. 2014;114:1619-1629.

Editor’s note: Tables 1, 2, 3, 6, and 8 that accompany this article are available online at www. andjrnl.org

C

ODING, COVERAGE, AND reimbursement for nutrition services are vital to the dietetics profession, particularly to those registered dietitian nutritionists (RDNs)*

*All registered dietitians are nutritionists, but not all nutritionists are registered dietitians. The Academy’s Board of Directors and the Commission on Dietetic Registration have determined that those who hold the credential Registered Dietitian (RD) may optionally use Registered Dietitian Nutritionist (RDN) instead. The two credentials have identical meanings. 2212-2672/Copyright ª 2014 by the Academy of Nutrition and Dietetics. http://dx.doi.org/10.1016/j.jand.2014.07.003

ª 2014 by the Academy of Nutrition and Dietetics.

who provide clinical care. Efforts to implement health care reform and achieve the triple aims of improved health outcomes, patient safety, and cost effectiveness underscore the importance of coverage of nutrition services for both the prevention and cost-effective treatment of disease. The Patient Protection and Affordable Care Act1 incorporates the provision of selected nutrition services as essential benefits, although the role of the RDN in delivering these services remains open to interpretation by payers. These include dietary counseling for adults at risk for cardiovascular disease and obesity counseling for children and adults. The availability of medical nutrition therapy (MNT) for Medicare beneficiaries with diabetes and/or chronic kidney disease and post kidney transplantation is unchanged.2 The Academy of Nutrition and Dietetics (Academy) has long championed the RDN’s expertise in the delivery of nutrition services and has

supported the provision of reimbursement for nutrition services, especially MNT, as a part of standard health insurance benefits. The Academy’s position3 on reimbursement is based on the following rationales:














a healthy lifestyle and consumption of a nutritious diet can delay and/or prevent the onset of chronic diseases/conditions; MNT is effective in the resolution and/or management of acute and chronic disease states; all Americans deserve access to high-quality, cost-effective care; MNT is an essential component of case management and transitional care coordination; and MNT is cost effective.

It is important for the Academy to periodically administer a national coding survey as part of an ongoing effort to understand the factors that impact the RDN’s ability to deliver and to be

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FROM THE ACADEMY compensated for preventive and therapeutic nutrition services, including MNT. Health care professionals, including RDNs, who bill third-party payers for their services use a standardized numeric nomenclature (code sets) to describe and document services provision and to submit claims to providers. The Current Procedural Terminology (CPT) code set,4 maintained by the American Medical Association (www.ama-assn.org), and the Health Care Common Procedure Coding System (HCPCS),5 developed by the Centers for Medicare and Medicaid Services (www.cms.gov), are the standardized code sets used to detail services provision. Within the CPT/HCPCS system,4,5 the MNT codes set offers the best description of services provided by RDNs. The International Classification of Diseases, 9th/10th edition (ICD-9/ 10)6 is the code set that describes the disease/condition for which the service was prescribed. It is the referring physician who determines diagnostic codes. ICD 9/10 code determination and use is not a major subject of this survey, although both procedural (CPT/ HCPCS)4,5 and diagnostic (ICD)6 code set documentation are necessary for reimbursement to occur. Surveys of the coding practices and patterns of procedural code4,5 use were conducted by the Academy (formerly the American Dietetic Association) in 20067 and 2008 (unpublished data, K. T. Ayoob and colleagues, April 2008) to determine:









RDNs’ knowledge, understanding, and use of the MNT and/or alternative procedure codes to obtain reimbursement for nutrition services; barriers to MNT code use; payer reimbursement patterns for MNT services; reasons for not being a Medicare provider; need for additional codes for existing/emerging services; and practitioner and practice demographics.

The current survey built on and refined the prior surveys and asked respondents to characterize the complexity of the typical patient population served and time spent in the provision of initial, subsequent, and group visits. The frequency of use of ancillary staff was also assessed. Survey data will be used to help 1620

characterize and validate the existing MNT codes and to support nutrition services code revision and/or expansion.

METHODS Survey Development The 2013 survey was developed based on previous coding and coverage surveys7 (unpublished data, K. T. Ayoob and colleagues, April 2008). The committee assessed previously administered questions for understandability and relevance. Particular attention was given to questions with low response rates in prior surveys to determine whether those questions, or their response choices, were unclear. Based on input from the Coding Survey Methodology Task Force and the results of the pilot study, these questions were reworded or dropped from the survey. In light of the rapidly changing environment surrounding health care reimbursement policy and regulation, new questions were added. Additional areas of focus included:






detail about the patient population served; estimates regarding time spent providing initial and subsequent care; and clarification of the respondent’s role in practice management.

Once relevant questions and the structure of the survey were revised, a pilot survey along with a detailed usability and clarity feedback form were sent to a small sample (n¼50) of RDNs. Subjects in the pilot survey were offered a chance to win an iPad (Apple Inc) if they responded. Nine (18%) individuals responded to the pilot survey and provided feedback. The survey was then revised and simplified. This study was deemed exempt by the University of Tennessee Graduate School of Medicine Institutional Review Board. This study was deemed exempt under federal regulation 45 46.101 (b) CFR.8

Survey Population and Data Collection An e-mail invitation was sent to all member and nonmember RDNs in the Academy/Commission on Dietetic Registration database (September 2013) who had a valid e-mail address, resided in the United States, were not retired, and did not opt out of receiving e-mails

JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

(n¼82,262). An initial e-mail and one follow-up e-mail were sent to encourage participation. The survey was also announced on the Academy website (www.eatright.org), in Eat Right Weekly (three times), in the MNT Provider newsletter, on various Academy online communities, through State Affiliate/Dietetic Practice Group/Member Interest Group communications, and through Academy social media outlets. The current sampling methodology differs from that of prior surveys7 (unpublished data, K. T. Ayoob and colleagues, April 2008) in which an e-mail invitation was sent to all Medicare Part B providers and a randomly generated subset of the member/nonmember RDN clinical practitioners selected from work settings where they would be most likely to know of and be eligible to use MNT/ CPT codes. The prior surveys7 (unpublished data, K. T. Ayoob and colleagues, April 2008) were also opened to the general membership via promotions on the American Dietetic Association website and electronic communications vehicles, such as the CEO Digest and American Dietetic Association listservs similar to the Academy communications vehicles delineated here. The implications of this change are discussed in the Limitations section. The current survey was administered via Survey Monkey, and 5,840 RDNs (7.1%) responded. Information was gathered on practitioner type, area of practice, primary practice location, and practice setting for all subjects. Only subjects who indicated that they provided and/or managed the provision of outpatient MNT (either via a screening question or via write-in responses; n¼3,628) were included in the remainder of the survey. While the number of respondents with valid data varied by question, 3,015 (83.1%) of the included subjects completed the entire survey (based on responses to a question at the end of the survey asking whether the respondent wanted to be entered into a prize drawing). This provided the ability to estimate the proportion of subjects who were exposed to each question but who chose not to answer a particular question or questions because respondents had to click through each page of the survey in order to get to the final question. When appropriate, the number choosing not to respond to a question is reported. October 2014 Volume 114 Number 10

FROM THE ACADEMY Statistical Analyses Descriptive statistics were computed as mean, median, standard deviation, and minimum/maximum (for continuous variables) or as “n” and percent (for categorical variables). In addition, because previous surveys had found that responses to billing, coding, and reimbursement questions differed by practitioner type (MNT providers, clinical nutrition managers and manager/providers), descriptive statistics reported by practitioner type are provided when the number of responses obtained makes this a viable consideration. Responses given by clinical nutrition managers who do not provide direct patient care relate to the clinical nutrition practices and services provided by the group of RDNs that they supervise. When descriptive statistics were reported by practitioner type, bivariate tests were used to determine whether the responses of the practitioner type subgroups were statistically different. A c2 test of independence was used to assess association for categorical variables and one-way analysis of variance was used for continuous variables. Because one-way analysis of variance is robust against departures from normality in large samples, we report parametric estimates even though not all continuous variables were normally distributed. When continuous data were non-normal, nonparametric tests (KruskaleWallis) were used to confirm parametric findings. Post hoc tests were carried out by analyzing standardized residuals for c2 analyses and Bonferroni-corrected pairwise comparisons for analysis of variance. SPSS software (version 21, 2012, IBM Corp) was used for all analyses.

RESULTS Survey Respondents Over half (54.5%, n¼3,182) of the 5,840 RDNs who responded to the survey indicated that they were providers of MNT in ambulatory care settings, 8% (n¼467) were both providers of MNT and managers of RDNs providing MNT in ambulatory care settings (manager/ providers), and 3.5% (n¼204) were RDN managers indicating they supervised clinical nutrition services provision only. One third of the respondents (33%, n¼1,930) indicated that they were not members of any of these October 2014 Volume 114 Number 10

practitioner type subgroups. Fiftyseven respondents (1%) did not provide an answer to the question of MNT provision and were removed from the analysis. All respondents were asked to indicate their area(s) of practice (multiple areas could be selected). Clinical nutrition was the most commonly selected practice area by all three practitioner type subgroups (MNT providers, manager/providers, managers) (see Table 1, available online at www.andjrnl.org). In contrast, respondents who indicated that they neither provided MNT in an ambulatory care setting nor managed those who do most often selected community nutrition as their area of practice (25.5%, n¼492). Respondents who did not answer the question regarding MNT provision in an ambulatory care setting or who indicated that they do not provide or supervise MNT were removed from the analysis (this included 225 respondents who indicated in write-in responses that they only provide or only supervise inpatient services). After all respondents who did not provide or supervise outpatient MNT were removed, 3,628 subjects remained in the analysis. Subjects retained for the analysis were distributed across the United States (see Table 2, available online at www. andjrnl.org).

Practice Characteristics Respondents were then asked a series of questions about their practice. The large majority (86.8%, n¼3,051) indicated they were “employed by another” (that is, received a W-2 form for their dietetics work). This was consistent across practitioner type subgroups (see Table 3, available online at www.andjrnl.org). However, there was a statistically significant association between MNT providereonly status and primary employment status (c2¼27.24; P<0.001), with those who defined themselves as MNT providers more likely to be self-employed (receive a 1099 form). Approximately one quarter of respondents indicated acute or ambulatory care facilities as their primary practice setting (24.6% and 25.5%, respectively), though managers were significantly more likely than expected to work for a government agency or

acute-care outpatient facility, while providers were significantly less likely to work in an acute-care outpatient facility (see Table 3; available online at www.andjrnl.org). Providers and manager/providers were asked to estimate the mean number of hours they spent providing MNT in a “typical week.” The majority of both groups indicated that they spent between 0 and 20 hours a week providing MNT (65.8%, n¼1,926 for providers and 71.2%, n¼304 for manager/providers). Just under 30% of providers reported working between 21 and 40 hours a week (n¼859; 29.5%) and slightly less for manager/providers (n¼104; 24.4%). Number of hours worked per week was moderately correlated (r¼.417; P<0.001; n¼3,308) with the number of patients seen in a typical week (mean 25.226.3 for providers and 22.324.1 for manager/ providers). The majority of respondents indicated that their practice used support staff (55.1%, n¼1,730). RDNs were asked to indicate whether they carried malpractice insurance and the source of that insurance (Table 4). There was a statistically significant association between practitioner type and malpractice coverage (c2¼70.13; P<0.001). Managers were significantly less likely than expected to carry their own malpractice insurance, and more likely to be covered under their employer’s malpractice insurance. In contrast, manager/providers were significantly more likely than expected to carry their own malpractice insurance as well as be covered under their employer’s insurance, and were less likely to answer that they did not know. The typical patient seen by respondents had multiple diagnoses. Respondents were asked to indicate the proportion of their typical patients who had 0 to 1, 2 to 3, 4 to 5, or 6 or more conditions. All three practitioner type subgroups indicated that <20% of their typical patients had 0 to 1 diagnosis (providers: 18.8%; manager/providers: 19.1%; managers: 18.9%) (Figure 1). This indicates that, on average, >80% of patients seen by respondents have two or more diagnoses. The mean proportions of typical patients in each category of number of diagnoses were similar except for patients with six or more diagnoses (F¼863.94; P<0.001). Providers reported a slightly greater proportion (mean¼12.08%, standard deviation¼19.18) of patients with

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FROM THE ACADEMY Table 4. Malpractice insurance coverage by practitioner type: Academy of Nutrition and Dietetics 2013 coding survey Malpractice insurance coverage (P<0.001)

Providers

Manager/Providers

Managers

Total

ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒn (%)ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ! Chose not to answer

8 (0.3)

Yes, I carry my own malpractice insurance

0 (0.0)

1 (0.5)

9 (0.3)

669 (23.1)

78 (18.5)

9 (4.7)

1,251 (43.2)

209 (49.6)

209 (66.6)

1,586 (45.2)

Yes, I have both my own coverage and coverage through my employer

282 (9.7)

57 (13.5)

21 (11.1)

360 (10.3)

No

362 (12.5)

50 (11.9)

19 (9.9)

431 (12.3)

Yes, my employer has told me I am covered under their policy

I don’t know Total

six or more diagnoses than managers (mean¼8.06%, standard deviation¼11.77). The provider group reported >75% of their patients having two or more diagnoses, with between 30% and 40% having four or more diagnoses.

Code Use Respondents were asked about their patterns of code use (both MNT CPT and other CPT codes). Results from the 2013 survey were similar to those of previous surveys7 (unpublished data, K. T. Ayoob and colleagues, April 2008). Across surveys, approximately 90% of RDNs who indicated using MNT CPT codes used codes 97802 and 97803. Use of the other MNT CPT codes (97804, G0270, G0271) was lower—all <40%. There was a significant association between knowledge of MNT CPT code

756 (21.5)

326 (11.2)

27 (6.4)

15 (7.9)

368 (10.5)

2,898 (100.0)

421 (100.0)

191 (100.0)

3,510 (100.0)

use (codes 97802, 97803, 97804) and practitioner type (c2¼53.28; P<0.001). Both manager/providers and managers were significantly more likely than expected to indicate using the MNT CPT codes and significantly less likely to respond “I don’t know.” Providers were significantly less likely to indicate that they used other (non-MNT) CPT codes. If respondents indicated that they did not use the codes (n¼759), they were asked to select from among a list of reasons why they did not use the MNT CPT codes. The most common reason given for not using MNT CPT codes was “Do not bill insurance plans” (59%, n¼448), followed by “Someone else (eg, billing department) determined code use” (32%, n¼243), which is similar to the responses in previous coding surveys. Respondents were also asked to estimate the average amount of face-toface time spent providing services for

each of the MNT CPT codes and the group codes (Table 5). For both 97802 (the initial visit) and 97804 (the group visit), a 60-minute increment was most frequently selected (52.0% and 13.8%, respectively). A 30-minute increment was most commonly selected for the subsequent visit individual and reassessment with intervention individual and group service codes, respectively (97803, G0270, and G0271). Of note, however, was the difference in the proportion of respondents who indicated that they did not use the codes or did not know/did not answer their standard time increment. For the individual service code (97802), >90% provided an estimate of time spent providing the service. In contrast, for the group service code (97804), >60% of respondents answered that they did not use the code, did not know, or chose not to answer this question. These responses are similar to responses from prior surveys7 (unpublished data, K. T. Ayoob and colleagues, April 2008). Approximately half (49.8%, n¼1,628) of the respondents indicated that they did not use other CPT codes. There was also a significant difference by practitioner type for non-MNT CPT code use (c2¼27.10; P<0.001), with manager/ providers being significantly more likely than expected to indicate that they did use other CPT codes as well as less likely to answer that they did not know.

Billing Figure 1. Mean proportion of patients with number of conditions (by practitioner group). 1622

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Respondents were asked to indicate the number of years they or the organization they worked for had billed for October 2014 Volume 114 Number 10

FROM THE ACADEMY Table 5. Most common estimated increment of face-to-face time spent providing medical nutrition therapy servicesa: Academy of Nutrition and Dietetics 2013 coding survey

Code

Most common time increment (% indicating)

97802

60 min (52.0%, n¼746)

97803

30 min (47.8%, n¼683)

5.0

3.5

97804

60 min (13.8%, n¼197)

10.8

54.9

G0270

30 min (9.4%, n¼133)

27.0

51.7

G0271

30 min (5.5%, n¼78)

25.8

58.8

Not answered/unsure

Do not use

ƒƒƒƒƒƒƒƒƒƒƒƒƒ%ƒƒƒƒƒƒƒƒƒƒƒƒƒ! 3.5

1.0

a

Proportions across all practitioner groups.

nutrition services. The majority of RDNs (n¼1,830, 56.6%) entered 0 years, with 46.9% (n¼585) of these indicating that they do not charge and 52.2% (n¼956) indicating that they did not know how long they had been charging (1%, n¼16 respondents chose not to answer). Of the 1,343 that indicated more than 0 years, respondents differed significantly by practitioner type subgroup in the number of years billing (F¼9.60; P<0.001), with providers indicating significantly fewer years billing (10.959.68) than either manager/providers (13.058.64; P¼0.009) or managers (14.569.46; P¼0.001). Respondents were asked what type of practice management procedure(s) they used when billing patients/clients for their services. The majority of respondents (68.2%, n¼1,621) across all practitioner type subgroups indicated that they used an internal billing

department (see Table 6, available online at www.andjrnl.org). Just under half (48.2%, n¼1,627) of the respondents indicated that they were Medicare providers (Table 7). There was a significant association between practitioner type and whether the respondent was a Medicare provider (or knew whether he or she was) (c2¼12.70; P¼0.013). Manager/providers were significantly less likely than expected to answer “I don’t know.” A similar billing pattern was observed in prior surveys. The majority of respondents indicated that they did not bill incident to physician services (61.8%, n¼2,013). Practitioner type subgroups were significantly different in terms of whether they billed incident to physician services (c2¼29.92; P<0.001). Respondents who were managers were significantly more likely than expected to respond “Yes.” Respondents

Table 7. Medicare provider status by practitioner type: Academy of Nutrition and Dietetics 2013 coding survey Medicare provider status

Providers

Manager/ providers

Managers

Total

ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ ƒ n (%)ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ ƒ! Medicare provider (P¼0.013) Yes

1,315 (47.3)

213 (52.3)

99 (53.2)

1,627 (48.2)

No

938 (33.7)

141 (34.6)

63 (33.9)

1,142 (33.9)

Don’t know Total

527 (19.0)

53 (13.0)

24 (12.9)

604 (17.9)

2,780 (100.0)

407 (100.0)

186 (100.0)

3,373 (100.0)

October 2014 Volume 114 Number 10

who were manager/providers were significantly less likely than expected to select “I don’t know” and significantly more likely to select “No.” Nearly half (47.5%, n¼1,518) of the respondents indicated that they billed third-party payers (consistent with the 20067 and 2008 [unpublished data, K. T. Ayoob and colleagues, April 2008] surveys). There was a significant difference by practitioner type (c2¼54.67; P<0.001). Managers or manager/providers were significantly more likely than expected to answer “Yes” and significantly less likely to select “No” or “I don’t know.” Respondents were asked to estimate the proportion of their payer mix from each payer category. Of the 1,540 respondents who indicated that they bill third-party payers, 89.5% (n¼1,379) provided an estimate of their payer mix. For all practitioner-type subgroups, Medicare and private/commercial insurance both accounted for approximately one third of their payer mix (Figure 2). Respondents who were providers or manager/providers both reported private/commercial insurance as the highest proportion, followed closely by Medicare. For respondents who were managers, the order was reversed, with Medicare being a slightly higher proportion of third-party payers than private/commercial insurance.

Reimbursement Respondents were asked whether they had established a usual and customary fee for nutrition services delivery. Only about one third (32.0%, n¼1,006) indicated that they had, while 44.5% (n¼1,402) indicated that they did not know (see Table 8, available online at www.andjrnl.org). Respondents were also asked to estimate the proportion of their usual and customary fee that is typically reimbursed by different types of payers. A relatively low proportion of respondents provided this estimate, with a low of 242 for workers’ compensation to 483 for self-pay. Of those who did respond, over half of the respondents indicated that they typically received 0% of their usual and customary fees from Medicaid (57%, n¼203) or workers’ compensation (84.7%, n¼205). The self-pay category was the only payer for whom over half (53.8%, n¼260) of the respondents indicated that they typically

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FROM THE ACADEMY

Figure 2. Respondent payer mix for reimbursement of medical nutrition therapy services by practitioner type. received 100% of their usual and customary fee. Providers, managers, and manager/providers did not differ in their estimates for any of the payer groups except Medicaid/state welfare (P¼0.016). For percent of usual Medicaid/state welfare fees reimbursed, 61.8% of providers indicated that 0% was typically reimbursed compared to only 34.4% of managers. In contrast, 12.5% of managers indicated that 100% of their usual and customary fee was reimbursed by Medicaid/state welfare compared to only 6.9% of providers.

Respondents were asked whether they participated in the Physician Quality Reporting System, a reporting program that currently uses incentive payments and adjustments to encourage reporting of quality of care information by eligible professionals.9 Responses differed significantly by practitioner type (c2 ¼16.24; P¼0.013) with managers and manager/providers significantly less likely to respond “I don’t know.” However, participation in the program by all groups was low, with a total of only 10.4% of respondents indicating participation.

Table 9. Diseases or conditions for which reimbursement is received from thirdparty payers (n¼1,221)a: Academy of Nutrition and Dietetics 2013 coding survey %b

Condition

n

Diabetes (DM)

1,071

87.7

740

60.6

Overweight/obesity Renal disease

685

56.1

Gestational diabetes (GDM)

582

47.7

Dyslipidemia (eg, elevated cholesterol, triglyceride levels)

576

47.2

Hypertension

483

39.6

Prediabetes

479

39.2

Celiac disease/nonceliac gluten sensitivity

475

38.9

Bariatric surgery

420

34.4

Gastrointestinal disorders (eg, Crohn’s disease)

419

34.3

Eating disorders

384

31.4

Abnormal weight gain

381

31.2

Failure to thrive

368

30.1

Food allergies

343

28.1

a

66.3% of survey respondents did not answer this question. As a percent of subjects who answered the question.

b

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Respondents were also asked whether they were aware of limits or caps to the number of visits, code units, or dollar amounts reimbursed by payers other than Medicare. Over half (52.5%, n¼1,619) of the respondents chose not to answer the question, with only 17.2% (n¼529) indicating that they were aware of payer caps. Respondents were provided with a list of diseases and conditions and asked to select all diseases or conditions for which they receive reimbursement from third-party payers for MNT services. Only 40.5% (n¼1,221) of respondents who completed the survey indicated at least one disease or condition for which they received third-party reimbursement (Table 9).

DISCUSSION Limitations While questions about MNT CPT code use were asked in each of the surveys, the structure of the questions changed across the surveys. In the 20067 and 2008 (unpublished data, K. T. Ayoob and colleagues, April 2008) surveys, the number of nonresponses for the questions was quite high. In 2013, several questions were restructured based on the experience of previous surveys and based on a pilot test of the newly structured survey early in 2013. As a result, the proportion of responses to the MNT CPT code use variables increased dramatically—from 77% and 72% in the 20067 and 2008 (unpublished data, K. T. Ayoob and colleagues, April 2008) surveys, respectively, to 92% in the 2013 survey. While the increased response rate is an improvement from prior surveys, it limits the ability to compare the results of the 2013 survey to the earlier surveys. The current sampling methodology differs from that of prior surveys7 (unpublished data, K. T. Ayoob and colleagues, April 2008) where an e-mail invitation was sent to all Medicare Part B providers and a randomly generated subset of the member/ nonmember RDN clinical practitioners selected from work settings where they would be most likely to know of and be eligible to use MNT CPT codes. The prior surveys7 (unpublished data, K. T. Ayoob and colleagues, April 2008) were also opened to the general membership via promotions on the website and electronic communications vehicles, such as October 2014 Volume 114 Number 10

FROM THE ACADEMY the CEO Digest and American Dietetic Association listservs similar to the Academy communications vehicles delineated in the current methods. Again, while this change in methodology is an improvement over the earlier surveys, in some cases it limits the ability to make comparisons across surveys. The reader is cautioned against interpreting differences between survey years as evidence of a secular trend in MNT CPT code use. For example, the number of respondents who are Medicare providers seems to precipitously drop between the previous surveys and 2013. However, Medicare providers were oversampled in previous surveys and, therefore, this likely represents a change in sampling strategy with a more accurate reflection of the membership as a whole, rather than a true change in number of Medicare providers. Therefore, only directional trends and similarities are reported here. RDNs providing MNT services when employed by someone else appear to have limited knowledge of coding, billing, and reimbursement for their services. From both an ethical and legal standpoint, such lack of knowledge puts the provider at risk because ultimately he or she is responsible for all billing done under his or her National Provider Identifier number.10 Also, it compromises the ability of the RDN to effectively retain and expand their services and role as part of the health care team.

Implications Although many RDNs indicate that they carry malpractice insurance, the Academy’s Coding and Coverage Committee remains concerned that approximately one in five practitioners (22.8%) responded that they “do not” or “don’t know” whether they carry malpractice insurance (Table 4). Under state law, a patient may pursue a civil claim against physicians or other health care providers (medical malpractice) if the health care provider causes injury or death to the patient through a negligent act or omission.11 Although nutrition-related claims are not prevalent, most states require malpractice insurance coverage for health care professionals providing direct patient care.12 The Academy/Commission on Dietetic Registration Code of Ethics13 requires conformity with state law. Consistent with trends noted by the American Hospital Association14 and October 2014 Volume 114 Number 10

Centers for Medicare and Medicaid Services,15 RDNs providing MNT reported that the average patient seen has multiple diagnoses, resulting in increased complexity of decisionmaking, nutrition care planning, and coordination of care. Increasing rates of obesity and its associated comorbidities are cited as contributors to the growth in the population of seniors with multiple chronic conditions. RDNs are uniquely qualified to assist patients in the cost-effective prevention and/or treatment of lifestyle factors that contribute to obesity, diabetes, hypertension, stroke, and other nutritionrelated diseases. End-stage renal disease beneficiaries represent a disproportionate share of Medicare spending.15 Timely provision of MNT in this population can improve health outcomes and reduce costs.16,17 RDNs are primary users of the MNT codes to bill for services provided to individuals for initial (97802) and follow-up (97803) visits because the CPT manual4 advises physicians to use the Evaluation and Management Codes set when providing such services. Use of CPT codes by RDNs for the provision of other types of services is limited. Use of the MNT codes for group services provision (97804) and the HCPCS G-codes that facilitate MNT reassessment and subsequent individual or group intervention for Medicare beneficiaries in the same year when there has been a change in diagnosis, medical condition, or treatment regimen continues to be suboptimal. RDNs appear to be foregoing opportunities to provide additional hours of MNT services to Medicare beneficiaries using code G0270 or G0271 when medically necessary. Opportunities to further improve nutrition-related outcomes in these beneficiaries are not being realized. Group services delivery has been shown to be an effective strategy that results in improvements in knowledge, body mass index, health-related quality of life, and glycemic control.18 As team-delivered care becomes more fully integrated into health care delivery systems, group visits will become an increasingly important facet of “new models of care” that conserve and extend professional time, improve health outcomes, and enhance cost effectiveness.19 RDNs must become more aware of, and

considerably increase the utilization of, this vehicle for MNT services delivery if we wish to remain the premiere provider of high-quality, efficient, costeffective nutritional care.

Clinical Application Educational Needs. Similar to previous surveys7 (unpublished data, K. T. Ayoob and colleagues, April 2008), RDNs knowledge of basic practice management concepts is limited and needs to be enhanced if they are to maximize opportunities for third-party payment for their services. Specific needs identified by this survey include:









need to carry malpractice insurance; need to establish a “usual and customary fee”; formal policies/procedures for tracking rates of reimbursement; how to use existing HCPCS Gcodes to provide additional MNT services for patients who have developed an additional disease/ condition or experienced a change in health status; knowledge of “caps”—limits to services provision; and knowledge of diseases or conditions for which reimbursement is received.

The Academy has developed a number of online and print practice management and practice advocacy resources for RDN use that can be found at www.eatright.org/coverage (members only), www.eatright.org/ mnt (members only), and www. eatright.org/shop (members and nonmembers). These include but are not limited to information on how to become credentialed as a Medicare provider and/or provider with other third-party payers, how to access information related to provision of services “across state lines”; and how to promote the value of MNT provision to Patient Centered Medical Homes, Accountable Care Organizations, and physician practices to support inclusion of RDNs and nutrition services.

Emerging Trends Responses to this survey also helped to identify several emerging trends related to coding and billing for nutrition services. While Medicare coverage

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FROM THE ACADEMY determinations and payment policy are consistently applied at the national level, coverage and payment for MNT by private payers occur inconsistently and varies by state, carrier, and often by specific plan(s) offered per carrier. In open-ended responses, survey participants noted a perceived increase in opportunities to bill and receive payment for MNT services, particularly for obesity, as a result of preventive service requirements under the Patient Protection and Affordable Care Act. This trend has created the need for provider education on how to appropriately code and bill for such services, to document initial and sustained efficacy of the service provided, and how to market this information to private carriers to expand coverage of MNT services within the private-payer realm. As shown by this survey, and by recent Centers for Medicare and Medicaid Services data,20 few RDNs are participating in the Medicare Physician Quality Reporting System program, a program that has the potential to impact Medicare payments to all eligible providers. Although provider participation in this program is voluntary, beginning in 2015, Medicare Feefor-Service providers will see their payments reduced if they do not meet satisfactory reporting requirements.21 Private payers have expressed interest in the use of quality measures to improve efficiency and to standardize improved health care outcomes.22 Many acute-careeassociated outpatient facilities choose not to bill for MNT services. The small number of patients seen and/or the low rate of payment received for services rendered limits its perceived fiscal benefits. Facility billing departments frequently do not know how to code/bill for MNT services or do not believe the time invested in billing is recovered in payment. Because independent billing for nutrition services in inpatient environments is not allowed (considered part of meals/other hospital services),23 many facility-based RDNs have limited to no knowledge of billing and coding practices and do not see the need to know this information. The increased focus on quality, safety, and readmissions reduction has increased recognition of the importance of optimizing the patient’s nutritional status to improve or 1626

maintain health and quality of life.24,25 However, organizations still need assistance in recognizing and valuing the depth and breadth of MNT services provided by RDNs and in identifying the revenue stream that will support their provision, as it is often indirect. A potential trend observed in this survey is the increased number of RDNs who indicated that they “do not bill insurance plans.” This seems to be an emerging trend in physician practices as well.26 More and more providers are frustrated with the paperwork, phone calls, multiple and ever-changing forms, and other issues that make verifying benefits and receiving third-party payment difficult, time consuming, and costly. Cutting out the “middle man” has allowed some providers to deliver necessary intervention and additional preventive care without unnecessary administrative protocol. “Self-pay-only” policies and “concierge medicine” are examples of evolving practice models that reduce the administrative burden of health care delivery, improve outcomes, and reduce costs, and that increasing numbers of providers seem to find attractive.27 Respondents identified a number of additional coding/coverage needs that were delineated in the open-ended portion of the survey. Many of these relate to expansion of the Medicare benefit to encompass provision of nutrition services to patients facing bariatric surgery, and those with nutrition-related diagnoses such as prediabetes, gastrointestinal disorders (ie, celiac disease), eating disorders, and cancer. Inclusion and standardization of MNT benefits offered by state Medicaid programs are needed to improve the health and well being of this underserved population, who frequently have very limited access to foods that would support/sustain health and to MNT services critical to disease prevention and treatment. All members of the Academy must work together to support these and future efforts to expand nutrition services access and coverage for all Americans.

SUMMARY It is critical that RDNs bill for clinical nutrition services in all settings where billing for RDN services is allowed. The MNT codes should be used to document

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and bill for RDN services whenever possible. Use of the MNT codes allows payers to track utilization of RDN services, facilitates RDN tracking of outcomes, and provides recognition of the RDN’s impact upon the nutritional health and well being of the patients that we serve. MNT code use helps to standardize the service provided and offers a common basis for research to document the effectiveness and quality of MNT. Research that documents the sustained health improvement impact of MNT services is needed to solidify the position of the RDN as a critical member of the health care team and to drive coverage and payment policy. As knowledge and use of the MNT codes continues to spread between both the dietetics and payer communities, we anticipate increased code utilization and payment for the MNT services RDNs currently provide and the development of additional descriptors for nutrition-related services targeted to specific diseases and conditions. The Academy Coding and Coverage Committee will use the information obtained from this survey to continue to develop and advocate for additional codes that RDNs can use in the provision of nutritional care. As pay-for-performance reimbursement9,21,22 is implemented across health systems and disciplines, RDNs must demonstrate cost efficiency, sustained procedure effectiveness, and patient-centered quality care. Coverage and institutional/individual provider reimbursements are tied to these norms. Nutrition departments and RDNs must, at minimum, “break even” and, optimally, be centers for revenue generation. RDNs (irrespective of work setting) and the Academy have specific and complementary roles in assuring the provision of cost-effective, billable nutrition services (Figure 3). Through participation in continuing professional educational opportunities available to members at the district, state, and national levels, RDNs can develop the advocacy and practicemanagement skills needed to ensure that MNT remains an effective and covered health care benefit. Working together, the Academy and its members can position RDNs as essential members of a health care team whose cost-effective services optimize the health and wellness of all consumers. October 2014 Volume 114 Number 10

FROM THE ACADEMY Action

RDN role

Academy role

Become credentialed

Obtain National Provider Identifier (NPI) and provider status for Medicare (MC)/Medicaid/state welfare (MA) and other relevant commercial payers

Links to NPI and MC and other relevant websites related to provider credentialing (www.eatright.org/coverage, www.eatright.org/mnt)

Negotiate contracts

Obtain and utilize copies of payer policies, contract provisions, codes, your patient’s outcomes (aggregate data), and negotiation skills to obtain reimbursement for Medical Nutrition Therapy (MNT) via current and potential payer streams (ie, MC, MA, commercial insurers, workers’ compensation)

Offer negotiation skills development options Regularly collect/analyze RDN code use data to try to influence coverage and payment policy regarding MNT/RDN services

Use evidence-based nutrition practice guidelines (EBNPG)

Use EBNPG to standardize and optimize nutrition services delivery

Systematically develop, review and revise EBNPG

Bill for MNT

Periodically review coding/billing policies/procedures Utilize Academy resources to assist in billing for services you provide according to payer contracts and policies

Systematically develop, review, and revise practice management educational resources Revise/maintain/promote use of current codes sets Emphasize the necessity of coding and billing for services provided

Track outcomes and services requests

Track patient outcomes including uploading data to Academy of Nutrition and Dietetics Health Informatics Infrastructure (ANDHII) and participating in Dietetics Practice Based Research Network (DPBRN) projects Track referrals/requests for services provisions and satisfied patient testimonials Use to expand range of coverage and reimbursement for the services you provide

Provide infrastructure, training and support for outcomes tracking and research projects through DPBRN and ANDHII (www.eatright.org/members/DPBRN/, www.andhii.org/info/)

Expand services provision

Provide nutrition and lifestyle-related services within state licensure laws/scope of practice provisions, personal competency, and payer policy

Identify/develop codes to expand nutrition services provision that may be billed to MC/MA and/or other commercial payers (ie, case management, transitional care)

Positively influence coverage and compensation determinations

Routinely participate in Academy coding and coverage surveys Participate in nutrition services advocacy activities at the local, state and national level in coordination with Affiliate Public Policy Panel

Present relevant data in external code creation/valuation venues to facilitate and expand coverage and compensation for RDN services Facilitate grassroots advocacy Collaborate with physician and nonphysician specialty societies to optimize nutrition services delivery

Figure 3. Examples of registered dietitian nutritionist (RDN) and Academy of Nutrition and Dietetics (Academy) roles in the provision and expansion of safe and effective billable nutrition services. Adapted with permission from White et al.7

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FROM THE ACADEMY References 1.

The Patient Protection and Affordable Care Act (PPACA), Pub. L. No. 111-148, 124 Stat. 119, March 23, 2010.

2.

Code of Federal Regulations. Title 42, Chapter IV, Subchapter B, Part 410, Subpart G, Section 410.132: Medical Nutrition Therapy. Fed Reg. November 1, 2001;66(212).

3.

Academy of Nutrition and Dietetics. Practice paper: The role of nutrition in health promotion and chronic disease management. J Acad Nutr Diet. 2013;113(7):972. http://www.eatright. org/About/Content.aspx?id¼6442476997. Accessed June 24, 2014.

4.

American Medical Association. CPT 2104 Professional Edition. Chicago, IL: American Medical Association; 2014.

5.

Buck CJ, ed. 2014 HCPCS Level II, Professional Edition. 14th ed. Chicago, IL: American Medical Association; 2014.

6.

Buck CJ. ICD-9-CM 2014 Professional Edition for Physicians. Vols. 1 and 2. Chicago, IL: American Medical Association; 2014.

7.

White JV, Ayoob KT, Benedict MA, et al. Registered dietitian’s practices and patterns of code use. J Am Diet Assoc. 2008;108(7):1242-1248.

8.

9.

10.

US Department of Health and Human Services. Code of Federal Regulations. Title 45: Public Welfare. Department of Health and Human Services. Part 46: Protection of Human Subjects. www.hhs. gov/ohrp/humansubjects/guidance/45cfr 46.html. Accessed September 6, 2013. Centers for Medicare and Medicaid Services. Physician Quality Reporting System: About PQRS. 2014. http://www.cms. gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/pqrs/index.html. Accessed June 24, 2014. Hodorowicz MA, White JV. Ethics in action. Elements of ethical billing for nutrition professionals. J Acad Nutr Diet. 2012;112(3):432-435.

1628

11.

Morton H. Medical liability/medical malpractice 2013 legislation. National Conference of State Legislatures. http:// www.ncsl.org/research/financial-servicesand-commerce/medical-liability-medicalmalpractice-2013-legislation.aspx. Updated January 13, 2014. Accessed May 12, 2014.

12.

Gershner RW. Medical nutrition therapy, private practice, and the reimbursement process: A quick primer to a complicated subject. Top Clin Nutr. 2007;22(1):70-81.

13.

American Dietetic Association/Commission on Dietetic Registration Code of Ethics for the Profession of Dietetics and Process for Consideration of Ethics Issues. J Am Diet Assoc. 2009;109(8):14611467.

14.

American Hospital Association. Are Medicare patients getting sicker? TrendWatch. December 2012. www.aha.org/.../ tw/12dec-tw-ptacuity.pdf. Accessed May 12, 2014.

15.

Centers for Medicare and Medicaid Services. Chronic Conditions among Medicare Beneficiaries, Chartbook, 2012 ed. Baltimore, MD: Centers for Medical and Medicaid Services; 2012.

16.

Gradwell E, Raman PR. The Academy of Nutrition and Dietetics National Determination Coverage Formal Request. J Acad Nutr Diet. 2012;112(1):149-176.

17.

Chang A, Van Horn L, Jacobs DR, et al. Lifestyle-related factors, obesity, and incident microalbuminuria: The CARDIA (Coronary Artery Risk Development in Young Adults) Study. Am J Kidney Dis. 2013;62(2):267-275.

18.

Rickheim PL, Weaver TW, Flader JL, Kendall DM. Assessment of group versus individual diabetes education. A randomized study. Diabetes Care. 2002;25(2): 269-274.

19.

Jaber R, Braksmajer A, Trilling J. Group visits for chronic illness care: Models, benefits, challenges. Fam Pract Manag. 2006;13(1):37-40.

JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

20.

Centers for Medicare and Medicaid Services. Table A8. Eligible professionals who participated in the Physician Quality Reporting System, by specialty (20092012). In: 2012 Reporting Experience Including Trends (2009-2013). Physician Quality Reporting System and Electronic Prescribing (eRx) Incentive Program Appendix. Bethesda, MD: Centers for Medicare and Medicaid Services; March 2014:34-36.

21.

Center for Medicare and Medicaid Services. Physician Quality Reporting System (PQRS) Overview. 2014 http://www.cms. gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/PQRS/Down loads/PQRS_OverviewFactSheet_2013_ 08_06.pdf. Accessed May 30, 2014.

22.

American College of Physicians. Position Statement: Use of Performance Measurements to Improve Physician Quality of Care. 2004. http://www.acponline.org/ ppvl/policies/e000984.html. Accessed June 2, 2014.

23.

Centers for Medicare and Medicaid Services. What does Medicare part A cover? https:// www.medicare.gov/what-medicare-covers/ part-a/what-part-a-covers.html. Accessed May 28, 2014.

24.

White JV, Stotts N, Jones SW, Granieri E. Managing post acute malnutrition (undernutrition) risk. JPEN J Parenter Enter Nutr. 2013;37(6):816-823.

25.

Slinin Y, Guo H, Gilbertson DT, et al. Prehemodialysis care by dietitians and first-year mortality after initiation of hemodialysis. Am J Kidney Dis. 2011;58(4): 583-590.

26.

Mahar M. Doctors who don’t take insurance: What does it mean for patients? The Health Care Blog. http://thehealthcareblog. com/blog/2008/07/09/doctors-who-don% E2%80%99t-take-insurance-what-does-itmean-for-patients/. Accessed May 12, 2014.

27.

Klemes A, Seligmann RE, Allen L, et al. Personalized preventive care leads to significant reductions in hospital utilization. Am J Manag Care. 2012;18(12):e453e460.

October 2014 Volume 114 Number 10

FROM THE ACADEMY AUTHOR INFORMATION J. S. Parrott is an associate professor, Department of Interdisciplinary Studies, School of Health Related Professions, and adjunct professor, Department of Quantitative Methods, School of Public Health, Rutgers, The State University of New Jersey, Newark. J. V. White is an emeritus professor, University of Tennessee Graduate School of Medicine, Knoxville. M. Schofield is director, Nutrition Services Coverage, Academy of Nutrition and Dietetics, Chicago, IL. R. K. Hand is senior manager, Dietetics Practice Based Research Network, Academy of Nutrition and Dietetics, Chicago, IL. M. B. Gregoire is executive director, Accreditation Council for Education in Nutrition and Dietetics, Chicago, IL; at the time of the study, she was director, Food and Nutrition Services, Rush University Medical Center, and professor and chair, Clinical Nutrition, Rush University, Chicago, IL. K. T. Ayoob is an associate professor of pediatrics, Albert Einstein College of Medicine, Bronx, NY. J. Pavlinac is director, Clinical Nutrition, Oregon Health & Sciences University, Oregon City. J. L. Lewis is CEO and president, Contemporary Nutrition, Inc, Havelock, NC. K. Smith is director, Morrison Chartwells Dietetic Internship, Fayetteville, GA. Address correspondence to: Jane V. White, PhD, RD, LDN, FADA, FAND, University of Tennessee Graduate School of Medicine, 8808 Sawyer Brown Rd, Nashville, TN 37221-1416. E-mail: [email protected]

STATEMENT OF POTENTIAL CONFLICT OF INTEREST No potential conflict of interest was reported by the authors.

FUNDING/SUPPORT There is no funding to disclose.

ACKNOWLEDGEMENTS Special acknowledgement to the members of the Academy of Nutrition and Dietetics 2013-2014 Coding and Coverage Committee for their oversight and review of this survey, and Ines M. Anchondo, DrPH, MPH, RD, LD (Coding Survey Methodology Task Force member).

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FROM THE ACADEMY Table 1. Survey respondent areas of practice by practitioner type: Academy of Nutrition and Dietetics 2013 coding survey Manager/ providers

Managers

None of the above

Area of practice

Providers

Total

Clinical nutrition

1,913 (60.1)

296 (63.4)

117 (57.4)

381 (19.7)

2,707 (46.8)

Weight management

1,084 (34.1)

145 (31.0)

32 (15.7)

197 (10.2)

1,458 (25.2)

766 (24.1)

113 (24.2)

30 (14.7)

329 (17.0)

1,238 (21.4)

Diabetes care

968 (30.4)

141 (30.2)

31 (15.2)

91 (4.7)

1,231 (21.3)

Community nutrition

558 (17.5)

91 (19.5)

30 (14.7)

492 (25.5)

1,171 (20.2)

ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒn (%)ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ!

Wellness/prevention

Education

627 (19.7)

92 (19.7)

22 (10.8)

380 (19.7)

1,121 (19.4)

Consult and private practice

636 (20.0)

85 (18.2)

9 (4.4)

202 (10.5)

932 (16.1)

Nutrition support

546 (17.2)

92 (19.7)

25 (12.3)

108 (5.6)

771 (13.3)

Long-term care

383 (12.0)

67 (14.3)

16 (7.8)

226 (11.7)

692 (12.0) 640 (11.1)

Pediatrics

452 (14.2)

59 (12.6)

18 (8.8)

111 (5.8)

Renal nutrition

475 (14.9)

53 (11.3)

16 (7.8)

85 (4.4)

629 (10.9)

Food and nutrition management

162 (5.1)

132 (28.3)

115 (56.4)

174 (9.0)

583 (10.1)

Gerontology

251 (7.9)

40 (8.6)

8 (3.9)

109 (5.6)

408 (7.1)

Oncology

269 (8.5)

39 (8.4)

18 (8.8)

36 (1.9)

362 (6.3)

Other

123 (3.9)

17 (3.6)

5 (2.5)

221 (11.5)

366 (6.3)

Sports nutrition

172 (5.4)

25 (5.4)

3 (1.5)

54 (2.8)

254 (4.4)

Business and industry

65 (2.0)

21 (4.5)

4 (2.0)

156 (8.1)

246 (4.3)

School nutrition

66 (2.1)

11 (2.4)

4 (2.0)

121 (6.3)

202 (3.5)

Vegetarian

146 (4.6)

21 (4.5)

4 (2.0)

24 (1.2)

195 (3.4)

Research

58 (1.8)

10 (2.1)

2 (1.0)

114 (5.9)

184 (3.2)

Communication/publication

55 (1.7)

12 (2.6)

1 (0.5)

56 (2.9)

124 (2.1)

Integrative and functional nutrition

88 (2.8)

16 (3.4)

0 (0.0)

13 (0.7)

117 (2.0)

Culinary

44 (1.4)

8 (1.7)

4 (2.0)

56 (2.9)

112 (1.9)

Policy and advocacy

20 (0.6)

7 (1.5)

4 (2.0)

43 (2.2)

74 (1.3)

Hunger/environmental nutrition

27 (0.8)

2 (0.4)

0 (0.0)

43 (2.2)

72 (1.2)

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FROM THE ACADEMY Table 2. Geographic region of survey respondents retained in the analyses: Academy of Nutrition and Dietetics 2013 coding survey

2013 Coding survey

2013 Compensation and benefits survey

ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒn (%)ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ! Self-employed

13

7

Census region New England

6

6

Mid Atlantic

13

13

East North Central

18

18

West North Central

10

10

South Atlantic

16

17

East South Central

5

6

West South Central

10

10

Mountain Pacific

8

6

14

14

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FROM THE ACADEMY Table 3. Employment status and work setting by practitioner type: Academy of Nutrition and Dietetics 2013 coding survey Providers

Manager/providers

Managers

Total

ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒn (%)ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ! Employment statusa (P<0.001) Chose not to answer

13 (0.4)

5 (1.2)

1 (0.5)

19 (0.5)

392 (13.5)

49 (11.6)

3 (1.6)

444 (12.6)

Employed by others (receives a W-2)

2,496 (86.0)

368 (87.2)

187 (97.9)

3,051 (86.8)

Total

2,901 (100.0)

422 (100.0)

191 (100.0)

3,514 (100.0)

Chose not to answer

421 (15.6)

52 (13.1)

20 (11.0)

493 (15.0)

Private practice

369 (13.7)

50 (12.6)

4 (2.2)

423 (12.9)

Ambulatory care facility (eg, clinic, physician’s office)

730 (27.1)

80 (20.1)

27 (14.9)

837 (25.5)

Managed care outpatient setting office

Self-employed (receives a 1099)

Primary work setting (P<0.001)

114 (4.2)

7 (1.8)

2 (1.1)

123 (3.8)

Wellness center or health club

86 (3.2)

13 (3.3)

3 (1.7)

102 (3.1)

Home health agency

43 (1.6)

5 (1.3)

1 (0.6)

49 (1.5)

Community or public health program

147 (5.4)

30 (7.5)

11 (6.1)

188 (5.7)

Acute-care facility (outpatient clinic)

588 (21.8)

130 (32.7)

88 (48.6)

806 (24.6)

Assisted-living facility Government agency or department Total

62 (2.3)

10 (2.5)

5 (2.8)

77 (2.3)

138 (5.1)

21 (5.3)

20 (11.0)

179 (5.5)

2,698 (100.0)

398 (100.0)

181 (100.0)

3,277 (100.0)

a

Significantly different proportions by practitioner group.

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FROM THE ACADEMY Table 6. Respondent billing practices by practitioner type: Academy of Nutrition and Dietetics 2013 coding survey Billing practice

Providers

Manager/providers

Managers

Total

ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒn (%)ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ! Bill third-party payers (P<0.001) Yes

1,177 (44.7)

227 (58.8)

114 (65.5)

1,518 (47.5)

No

820 (31.1)

101 (26.2)

39 (22.4)

960 (30.0)

Don’t know

639 (24.2)

58 (15.0)

21 (12.1)

718 (22.5)

2,636 (100.0)

386 (100.0)

174 (100.0)

3,196 (100.0)

Yes

147 (5.5)

29 (7.4)

17 (9.5)

193 (5.9)

No

1,620 (60.3)

277 (70.3)

116 (65.2)

2,013 (61.8)

918 (34.2)

88 (22.3)

45 (25.3)

1,051 (32.3)

2,685 (100.0)

394 (100.0)

179 (100.0)

3,257 (100.0)

208 (10.9)

34 (10.6)

22 (14.9)

264 (11.1)

1,283 (67.2)

225 (70.1)

113 (76.4)

1,621 (68.2)

247 (12.9)

45 (13.7)

14 (9.5)

Total Bill incident to physician services (P<0.001)

Don’t know Total Billing method Use billing service(s) Use an internal billing department Self bill; electronically

305 (12.8)

Self bill; paper

231 (12.1)

29 (9.0)

9 (6.1)

269 (11.3)

Provide patient/client with superbill

173 (9.1)

28 (8.7)

5 (3.4)

206 (8.7)

Totala

1,908

321

148

2,377

a

Percentages do not total 100 because respondents could select multiple responses to this question.

October 2014 Volume 114 Number 10

JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

1629.e4

FROM THE ACADEMY Table 8. Usual and customary fee and payer caps by practitioner type: Academy of Nutrition and Dietetics 2013 coding survey Providers

Manager/Providers

Managers

Total

ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒn (%)ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ! Usual and customary fees (P<0.001) Yes

780 (30.0)

151 (39.6)

75 (44.6)

1,006 (32.0)

No

610 (23.5)

88 (23.1)

42 (25.0)

740 (23.5)

Don’t know

1,209 (46.5)

142 (37.3)

51 (30.4)

1,402 (44.5)

Total

2,599 (100.0)

381 (100.0)

168 (100.0)

3,148 (100.0)

1,405 (55.2)

154 (41.3)

60 (36.4)

1,619 (52.5)

Yes

399 (15.7)

93 (24.9)

37 (22.4)

529 (17.2)

No

226 (8.9)

46 (12.3)

24 (14.5)

296 (9.3)

Aware of payer caps (P<0.001) Chose not to answer

Don’t know Total

1629.e5

515 (20.2)

80 (21.4)

44 (26.7)

639 (20.7)

2,545 (100.0)

373 (100.0)

165 (100.0)

3,083 (100.0)

JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

October 2014 Volume 114 Number 10