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Family physicians have a new option for providing nutrition counseling to Medicare patients with diabetes or renal disease. Medicare rules were recently finalized for medical nutrition therapy (MNT) codes 97802-97804, which provide payment for outpatient counseling by registered dietitians or nutritionists in an individual or group setting.
 
The codes, covered by Medicare effective Jan. 1, 2002, are:

97802 Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with patient, each 15 minutes

97803 re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes

97804 group (2 or more individual[s]), each 30 minutes.
 
 
Code 97802 should be used for the initial patient visit for an individual MNT and represents 15-minute increments. For follow-up individual visits, use 97803, again in 15-minute increments. Code 97804 is for group counseling, both initial and follow-up, provided in 30-minute increments.
 
Physician offices should know key facts about Medicare's rules for MNT codes:

 

The MNT codes can be used only for MNT provided by registered dietitians or nutrition professionals. Payment for these services goes to the registered dietitian or nutrition professional. "The physicians should be clear that these codes are not meant for them," says Emily Hill, PA-C, president of Hill & Associates, a consulting firm in Wilmington, N.C., that works with physician practices on coding and compliance.

 

The treating physician must refer the patient to the registered dietitian or nutrition professional for MNT.

 

Only two categories of Medicare patients diabetics and renal patients who have chronic renal insufficiency or who have received a kidney transplant within the past 36 months are eligible for MNT coverage. Patients with end-stage renal disease who are on dialysis are excluded.

MNT Allowed in Any Outpatient Setting 

Medicare will pay for MNT provided in virtually any outpatient setting, including the physician's office, an independent dietitian's practice or a hospital outpatient department. It will not pay when the services are provided to a patient during an inpatient stay at a hospital or skilled nursing facility because fees to these facilities already include MNT.
 
In physicians' offices that have a registered dietitian on staff, the dietitian cannot bill the MNT codes "incident to" the physician.
 
"The dietitians or nutritionists must have their own Medicare provider numbers," notes Catherine Trinidad, CPC, coder for Community Health Center Network, a network of seven community health centers in Alameda County, Calif.
 
The registered dietitian or nutritionist must enroll as a provider in Medicare, accept assignment and contact the local Medicare carrier to complete a Form HCFA-855 before billing for MNT services. The new specialty code for registered dietitians and nutrition professionals is "71."
 
Most family physician offices will refer patients to registered dietitians or nutritionists for therapy, so they will not use the codes in-house. However, Pam Michael, MBA, RD, LD, director of the American Dietetic Association Health Care Financing team, notes it is crucial that physicians know the rules for proper implementation of the Medicare MNT benefit. The patient's treating physician must order the MNT, indicating the medical necessity for the service and documenting a diagnosis of either diabetes or renal disease to support the referral.

 "This should be noted both in the patient's chart and in the referral to the registered dietitian," Michael says.

Only registered dietitians or nutrition professionals can provide MNT under the rules for Medicare Part B reimbursement. Medicare says the dietitian or nutrition professional must be licensed or certified in the state where the services will be provided as of Dec. 21, 2000, or, after that date, meet criteria that include earning a degree in the field, completing 900 hours of dietetics practice under the supervision of a registered dietitian, and becoming licensed or certified as a dietitian or nutrition professional in the state where the services will be performed. In states without licensure or certification programs, Medicare says, dietitians and nutrition professionals can qualify by completing the education and practice requirements above or being recognized as a registered dietitian by the Commission on Dietetic Registration.

Medicare has not finalized rules on the number of allowed visits and the duration of the benefit. The number of hours covered is likely to be different for diabetics than for renal patients. As this issue went to press, CMS was expected to issue a national coverage determination addressing those issues. That memorandum may also include a list of acceptable diagnosis codes. Ask your local Medicare carrier for a list of covered diagnosis codes.
 
Jane White, PhD, RD, a professor in the department of family medicine at the University of Tennessee at Knoxville, and the immediate past president of the American Dietetic Association, says Medicare coverage of MNT for diabetics will be "a real boon to patients" in family physician offices because numerous studies have shown the importance of diet in controlling the disease. White, who teaches nutrition to medical students and counsels patients on nutrition, notes that only an hour of nutrition counseling is included in current diabetes self-management training (DSMT) although diet is crucial.
 
According to Medicare rules, the MNT benefit for diabetics will be coordinated with DSMT. For now, Medicare limits patients to 10 hours of combined DSMT and MNT during the initial 12-month referral period. However, CMS is further considering this issue. Physicians should note that patients who have received initial DSMT within the past 12 months are not eligible to receive MNT unless the referring physician notes a change in diagnosis or medical condition that necessitates reassessment and additional therapy, or the patient has been diagnosed with renal disease since then. Hill notes that physicians should watch for further information from Medicare on application of the rules.
 
"Physicians and coders need to be aware that there will be further specificity from Medicare, which will be provided through their carriers," Hill says.

The payment established for the codes is less than dietitians wanted, and White says this is a major concern because it may limit beneficiaries' access to MNT, inadequately address patient needs, or undermine the availability of MNT services. "The reimbursement rate is not at a break-even point," she says.
 
Both 97802 and 97803 have been assigned .46 relative value units (RVUs) for each 15-minute increment, with a resulting national (not adjusted for region) Medicare payment of about $14.154 for each 15-minute increment. Code 97804 has an RVU of .18, resulting in a payment of $5.539 per patient for each 30-minute session. Medicare assumes that an average of five patients will attend group sessions.

Since the medical nutrition therapy codes were first published in CPT 2001, many private carriers have begun paying for them.
 
"Private payers will pay for a lot more reasons and generally pay a lot more [than Medicare] for the codes," says Carol Sissom, CPC, a senior healthcare consultant at the Indianapolis-based Health Care Economics Inc., which provides billing and coding services to 200 practices annually.
 
She notes that the MNT codes are not for patients with feeding tubes or receiving intravenous parenteral nutrition. However, they can be used with private payers in most other scenarios requiring medical nutrition therapy in all age groups, from low-birth-weight infants to elderly patients with chronic diseases. She gives an example: A 4-year-old child is brought to the physician's office by his parents, who are concerned that he is not eating well and not growing at a normal rate. If extensive tests rule out other problems, the physician may refer the child and parents for MNT.