MedGem® Reimbursement Guide
This guide is designed to offer basic information to assist providers in obtaining reimbursement using the MedGem® indirect calorimeter by Microlife Medical Home Solutions, Inc.
Product Overview
The MedGem device is a hand-held, self-calibrating indirect calorimeter that accurately measures oxygen consumption (VO2) to determine a patient’s resting metabolic rate (RMR)[1]. It is a FDA 510K cleared Class II medical device.
Clinical Justification
RMR represents the number of calories the body uses to maintain vital body function, accounting for up to 75% of a healthy person’s total daily energy expenditure and up to 100% for the diseased or critically ill. Previously, clinicians relied on estimation equations to predict RMR; however the equations have been shown to be inaccurate when applied to individuals[2]. Metabolism varies among individuals and is influenced by several factors including disease states, injury, illness, obesity, and weight loss. Knowing RMR allows clinicians to accurately determine a patient’s individual energy requirement playing a vital role in patient care. Measuring VO2 (RMR) will promote risk minimization, substantiate and support Medical Nutrition Therapy and positively influence patient outcomes.
Medical Necessity must be established in order for indirect calorimetry to be considered for reimbursement. Individual payers develop their own criteria for medical necessity. The measurement may not be considered medically necessary for weight management, and the coverage potential is higher if there is an underlying medical need, such as a disease state.
Validation
The MedGem is a valid and reliable indirect calorimeter in adults[3],[4] and children greater than 7 years of age[5].
Coding
Procedure Codes:
94690: oxygen uptake; expired gas analysis; rest, indirect
*Measurement can be billed separately or in conjunction with a patient office visit or medical nutrition therapy (MNT).
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
*The AMA CPT Information Services has verbally confirmed that 94690 is the most appropriate code for the MedGem® measurement. This coding list is not all-inclusive; for a complete list of coding options and descriptions, consult your CPT manual.
ICD-9-CM Diagnosis Codes: Two codes are encouraged, a primary code describing the disease state with medical necessity and a secondary code describing co morbidity. Please review the “Possible Reimbursement Coding Options” document.
Contract Negotiation & Pre-Authorization
The following actions assist in securing insurance benefits for the MedGem® measurement:
· Acquire a contract with insurance companies; provide Evidence Based Nutrition Plan and Outcome Data.
· Phone call to obtain pre-authorization, verify insurance benefits and determine if pre-authorization is required.
· If pre-authorization is needed in writing, the letter should include:
1. Patient’s brief medical history, complicating co-morbidities
2. Medical necessity of the procedure
3. Overall expected course or prognosis and projected outcome
4. Efficacy of the procedure
5. Diagnosis and procedure codes
*If pre-authorization is not available, we recommend the patient sign a Financial Liability Wavier in the event of a non-coverage decision.
Denied Claims
Reasons for Denial:
· Administrative error on the claim form - Carefully review the Explanation of Benefits for the reason or explanation of denial, confirm appropriate codes, verify correct Unique Physician Identification number, modifier, procedure code, diagnosis code and resubmit claim.
· A lack of medical necessity – ICD-9 code may need further detail; such as ‘uncontrolled’ Diabetes Mellitus
· Diagnosis code does not match with CPT code
· Lack of physician referral for services. Dietitian may need to include Nutrition Diagnosis: “Patient with excessive energy intake. Patient caloric intake is greater than expenditure. (Intake determined by diet recall and expenditure determined by indirect calorimetry). This could result in weight gain and complications associated with obesity.”
· CPT code 94690 may result in denial of pre-authorization or services as it is considered a “respiratory” code. We recommend informing the payer that this code has been confirmed by AMA CPT Information Services as an appropriate code for the procedure. If they continue to deny the claim, ask the payer if they prefer the claim to be submitted with an alternative code which they specify.
Request the insurance carrier send a written explanation of their appeal process. Your appeal letter should include a statement as to why the MedGem measurement was chosen and the reasoning other treatments were not pursued.
MedGem reimbursement cannot be guaranteed and is determined on an individual basis; many insurance carriers will cover the procedure if medical necessity is shown.
Preauthorization Letter Template
Date:
Payer Address:
Re: (Patient name, Subscriber number)
Dear ______:
My patient suffers from [insert patient’s diagnosis] and as a result I am seeking pre-authorization to measure [his/her] V02 to determine their precise Resting Metabolic Rate (RMR) and assess their energy expenditure needs. This procedure will promote risk minimization, positively influence patient outcomes and ensure the best nutritional care is provided.
Patient History:
· Detailed patient history with description of patient’s current status including diagnosis, complaints, and level of impairment. Describe functional impairments, and how the patient’s condition has impacted his/her activities of daily life.
· Previous interventional treatment efforts - noting procedures, medications, and/or therapies attempted; include outcome of each treatment.
· Statement as to what can be accomplished by performing the procedure (why this is an appropriate intervention at this point in the patient’s care; note therapeutic goals, anticipated outcomes; how this procedure might change or direct the patient’s course of treatment, etc.)
Coding and Charges
CPT 94690 Indirect Calorimetry – (estimated charge)
Medical Nutrition Therapy or Physician Office Visit (estimated charge)
Please confirm that the indirect calorimeter measurement is a covered procedure for [insert patient name] based on their medical necessity described above. I appreciate your timely response to this preauthorization request, as I am eager to move forward with the findings of this treatment.
Please contact me at if you have any questions.
Sincerely,
Practitioner Name
UPIN number
Phone Number
Appeal Letter Template
Date:
Payer Address:
Re: (Patient Name, Subscriber Number, Claim number)
Dear:
This letter is to appeal the denial of payment for claim listed above.
My patient suffers from (diagnosis) and as a result I performed a procedure to measure their Oxygen Consumption (VO2) to determine their precise Resting Metabolic Rate (RMR) and assess their caloric/energy needs. Measuring oxygen consumption and energy requirements is the most accurate basis for administering precise nutritional counseling and a necessary procedure to counsel my patient. Knowing their unique RMR will increase probability and rate of attaining optional health, minimize complications and ensure that the best care is provided to them.
Patient History – Any necessary details pertaining to patient. Include Supporting ICD- 9 Codes.
· Description of patient’s current status including diagnosis, complaints, level of functional impairments, and how the patient’s condition has impacted his/her activities of daily life.
· Previous interventional treatment efforts - noting procedures, medications, and/or therapies attempted; include outcome of each treatment.
· Statement as to what can be accomplished by performing the procedure (why this is an appropriate intervention at this point in the patient’s care; note therapeutic goals, anticipated outcomes; how this procedure might change or direct the patient’s course of treatment, etc.)
Coding and Charges
The CPT code 94690 was used because the AMA CPT Information Services stated this is the most appropriate code for the procedure. Supporting ICD-9 diagnosis codes are listed above in the Patient History. Please inform me if you would like me to re-submit the claim using another code and what that code would be.
I ask that you cover this necessary procedure for my patient. Please contact me if you need additional information.
Sincerely,
Practitioner Name
UPIN number
Phone number
© 2009 Microlife Medical Home Solutions, Inc. All rights reserved. Microlife and WatchBP are registered trademarks of Microlife Corp. MedGem is a registered trademark of Microlife Medical Home Solutions, Inc. .
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[1]Calculated using the Weir equation with a constant RQ value of 0.85 (RMR=6.931xVO2), Weir, J.B., New Methods for Calculating Metabolic Rate with Special Reference to Protein Metabolism. J Physiol, 1949. 109:pages 1-9.
[2] Frankenfield, D.C. et al. (2003) Validation of several established equations for resting metabolic rate in obese and no obese people. Journal American Dietetic Association. 103(9): p. 1152-9.
[3] Nieman, D.C, Trone, G.A., Austin, M.D. “A new handheld device for measuring resting metabolic rate and oxygen consumption.” Journal of the American Dietetic Association 2003; 103:588-593.
[4] Stewart, C.L., Goody, C.M., Branson, R. “Comparison of Two Systems of Measuring Energy Expenditure.” Journal of Parenteral and Enteral Nutrition. 2005; 29: 212-217.
[5] Nieman, D.C., Austin, M.D., Chilcote, S.M., Benezra, L. “Validation of a new handheld device for measuring resting metabolic rate and oxygen consumption in children.” International Journal of Sports Nutrition and Exercise Metabolism, 2005; 15: 196-184.