Coding and Billing- Medicare

Medicare MNT (Medical Nutrition Therapy)

Nutritional diagnostic, therapy, and counseling services provided by a registered dietitian or nutrition professional to manage disease.

CMS (Centers for Medicare & Medicaid Services)

Federal agency that administers Medicare and establishes regulations for Medicare MNT benefits.

Medicare MNT benefit

Medicare coverage that allows qualifying beneficiaries to receive MNT from eligible registered dietitians for specific diagnoses.

Medicare-covered MNT diagnoses

Type 1 diabetes, type 2 diabetes, gestational diabetes, and non-dialysis kidney disease, including kidney transplant patients.

Medicare MNT and obesity

Medicare may cover obesity counseling through the Diabetes Prevention Program or obesity behavioral therapy when requirements are met.

Non-covered MNT diagnoses

Diagnoses other than those specifically covered by Medicare; an RD generally cannot bill Medicare for MNT for these diagnoses under the MNT benefit.

Medicare Diabetes Prevention Program (MDPP)

A Medicare program that provides structured lifestyle and behavior-change services to help eligible individuals prevent or delay type 2 diabetes.

MDPP start date

Medicare Diabetes Prevention Program began in April 2018.

MDPP BMI requirement

BMI of ≥25 kg/m², or ≥23 kg/m² for Asian populations.

MDPP A1c requirement

Hemoglobin A1c of 5.7–6.4% within the previous 12 months.

MDPP fasting glucose requirement

Fasting plasma glucose of 110–125 mg/dL within the previous 12 months.

MDPP 2-hour glucose requirement

2-hour post-glucose level of 140–199 mg/dL within the previous 12 months.

MDPP duration

1 year of structured behavior-change sessions.

RD roles in MDPP

Dietitians can serve as program directors, coordinators, coaches, and master trainers.

CPT codes 97802, 97803, 97804

MNT codes approved by the AMA in February 2000.

Medicare MNT legislation

Legislation signed in December 2000 established Medicare coverage for MNT services.

MNT codes available to insurers

MNT CPT codes became available for use by insurers in January 2001.

G0270 and G0271

Medicare G-codes released in October 2002 for additional MNT following a change in diagnosis, medical condition, or treatment.

Medicare provider enrollment

Process of becoming an approved Medicare provider by completing the required enrollment applications.

Medicare provider

An RD who has enrolled with Medicare and can provide and bill for covered Medicare MNT services.

RD Medicare enrollment

RDs can enroll as Medicare providers at any time through the appropriate Medicare enrollment process.

RD non-enrollment option

An RD may choose not to enroll with Medicare and instead refer qualifying Medicare beneficiaries to an RD who is a Medicare provider.

Opting out of Medicare

An option in which a provider enters into a private contract with a Medicare beneficiary rather than billing Medicare.

Medicare malpractice insurance

RDs providing Medicare MNT as providers must have malpractice insurance.

NPI (National Provider Identifier)

A unique provider identification number required for submitting Medicare MNT claims.

Medicare carrier

The entity that processes Medicare enrollment and claims.

Medicare MNT-eligible settings

RD private practices, group RD practices, physician offices, ambulatory clinics, hospital outpatient services, and other eligible outpatient facilities.

Medicare Part B MNT

Medicare coverage for eligible outpatient MNT services.

Medicare Part B MNT non-eligible settings

Hospital inpatient services, skilled nursing facilities/long-term care, and dialysis centers are not eligible for Medicare Part B MNT reimbursement under this benefit.

Medicare MNT physician referral

A referral from the treating physician, primary care physician, or specialist coordinating the beneficiary's care that is required for Medicare MNT.

Episode of care

A period of treatment for a specific medical condition during which MNT services are provided.

Medicare referral requirements

A physician referral is needed for each episode of care, additional MNT during the first year, and follow-up MNT.

Calendar year rule

Medicare MNT referrals are based on calendar years rather than carrying unused initial hours into the next year.

New-year MNT referral

A beneficiary must receive a new referral for follow-up MNT hours in each calendar year.

Nationally recognized protocols

Evidence-based protocols, such as those developed by the ADA, that must be used when providing Medicare MNT.

Evidence-based guides for Medicare MNT

Practice guidelines covering gestational diabetes, type 1 and type 2 diabetes, chronic kidney failure/non-dialysis kidney disease, and obesity.

Evidence-based practice

Using current research, recognized protocols, and clinical guidelines to provide appropriate MNT.

CPT 97802

Initial MNT assessment and intervention, individual, face-to-face, billed in 15-minute units; used only for the initial MNT visit.

CPT 97803

Individual, face-to-face MNT re-assessment and intervention, billed in 15-minute units.

CPT 97804

Group MNT for 2 or more individuals, billed in 30-minute units.

MNT CPT units

Multiple units can be billed based on the amount of time spent providing the service; the code and number of units are listed on the claim form.

15-minute MNT rounding rule

For 97802, 7 minutes or less rounds down; 8 minutes or more rounds up to the next 15-minute unit.

CPT 97802 vs. 97803

97802 is used for the initial assessment/intervention, while 97803 is used for reassessment and follow-up intervention.

G0270

Individual, face-to-face MNT reassessment and subsequent intervention following a second referral in the same year because of a change in diagnosis, medical condition, or treatment regimen; billed in 15-minute units.

G0271

Group MNT reassessment and subsequent intervention following a second referral in the same year because of a change in diagnosis, medical condition, or treatment regimen; billed in 30-minute units.

Change in medical condition for G0270/G0271

A change in diagnosis, medical condition, or treatment regimen that requires a change in MNT and results in a second referral during the same year.

Basic Medicare MNT coverage

3 hours during the first year.

Additional first-year MNT

Additional hours may be covered when the treating physician determines there has been a change in medical condition, diagnosis, or treatment regimen requiring additional MNT.

Follow-up Medicare MNT coverage

2 hours in the second year and subsequent years.

Medicare MNT first-year benefit

3 hours of MNT unless additional medically necessary hours are ordered because of a change in condition, diagnosis, or treatment.

Medicare MNT follow-up benefit

2 hours of MNT in each subsequent year.

Medicare-covered diabetes diagnoses

Type 1 diabetes, type 2 diabetes, and gestational diabetes.

Medicare-covered kidney disease

Non-dialysis kidney disease, including patients who have received a kidney transplant.

Diabetes diagnostic criterion for MNT

Fasting glucose >126 mg/dL.

Prediabetes and Medicare MNT

Prediabetes/impaired fasting glucose alone is not covered under the Medicare MNT benefit.

Gestational diabetes criterion

Any degree of glucose intolerance with onset or first recognition during pregnancy.

Kidney disease GFR criterion

Glomerular filtration rate (GFR) of 15–30 mL/min/1.73 m².

Obesity criterion

BMI ≥30 kg/m².

Documentation

The written record of what was done with the client, when it occurred, and why it was done.

“If it wasn't documented, it wasn't done”

Documentation principle emphasizing that services must be properly recorded to demonstrate that they occurred and support billing.

Documentation story

Documentation should clearly explain what was done, when it happened, and why it was medically necessary.

Nutrition diagnosis documentation

Documentation of the RD's clinical thought process and reasoning behind the nutrition diagnosis and treatment.

Timely documentation

Completing documentation accurately and promptly after providing care.

Purpose of documentation – communication

Allows healthcare professionals to communicate important patient information.

Purpose of documentation – continuity of care

Helps ensure consistent care when multiple healthcare professionals treat the patient.

Purpose of documentation – legal protection

Provides a record of the care provided and clinical decisions made.

Purpose of documentation – research

Provides information that can be used for research and evaluation.

Purpose of documentation – reimbursement

Provides evidence that supports payment/reimbursement for services.

OIG (Office of Inspector General)

Government office that establishes and monitors requirements related to healthcare program integrity, including documentation and billing practices.

Complete documentation

Documentation must contain enough information to support the entire service; incomplete documentation may result in the service being considered non-billable.

Reason for visit

Documentation should explain why the patient is receiving the service.

Relevant history

Patient history that is important to the current nutrition assessment and treatment.

Physical examination findings

Relevant findings from the patient's physical examination that support assessment and treatment.

Prior diagnostic test results

Previous laboratory or diagnostic results relevant to the patient's care.

Assessment/clinical impression

The RD's evaluation and interpretation of the patient's nutrition-related condition.

Plan of care

The planned nutrition treatment and interventions for the patient.

CMS-1500 form

Standard claim form used to submit healthcare professional services for reimbursement.

Diagnosis-service link

The diagnosis code on the claim should be linked to and support the reason the service was provided.

Health risk factors

Patient factors that may increase the risk of disease or affect nutrition treatment.

Patient progress documentation

Documentation of changes in the patient's condition and progress toward nutrition goals.

Patient response to treatment

Documentation of how the patient responded to nutrition interventions.

Treatment revision

Changes made to the nutrition intervention based on the patient's response or changing condition.

Diagnosis revision

Updating the documented diagnosis when the patient's condition or clinical assessment changes.

ABN (Advance Beneficiary Notice of Noncoverage)

A form that informs a Medicare beneficiary that a service may not be covered by Medicare and that the patient may be responsible for payment.

ABN purpose

Gives the patient the opportunity to receive the service while understanding that Medicare may not pay for it.

ABN and non-covered diagnosis

An ABN should be used when providing a service that may not be covered by Medicare, such as MNT for a diagnosis outside the covered benefit.

ABN and billing

With an appropriate ABN on file, the provider can provide the service and attempt to bill Medicare while notifying the patient of possible financial responsibility.

No ABN on file

If an ABN was required but not obtained, the practice may be responsible for the cost of the service rather than being able to bill the patient.