Internal Medicine Coding Alert

Examples of changes that would qualify for additional MNT include a diabetic patient who moves from oral medication to insulin, a patient with gestational diabetes who requires frequent dietary modification, or a patient with diabetes who has a diabetic complication that requires tighter dietary control. For example, patients may qualify for additional MNT if their hemoglobin AIC levels are elevated or there is a change in lipid values, says Joan Hill, RD, CDE, LD, director of education at the Joslin Diabetes Center, a Boston-based clinical and research facility that is affiliated with Beth Israel Deaconess Medical Center and Harvard University.

Elias Siraj, MD, an endocrinologist in the department of endocrinology, diabetes and metabolism at the Cleveland Clinic Foundation in Ohio, says Medicare coverage of the MNT codes is important because it will give patients with diabetes additional opportunity to understand and improve dietary control. He notes that with or without other modalities of treatment, proper diet has been shown to help reduce the complications experienced by diabetic patients and thereby reducing the cost of treating the disease. "Overall, there is a great benefit to be achieved by increasing their access to the nutritionist," he says.

Renal patients, whose outcome is also influenced heavily by diet, including the amount of protein consumed, are also eligible for more frequent MNT when they have changes in medical condition, diagnosis or treatment regimen, such as a clinically significant decrease in renal function, signs of malnutrition, a lack of understanding of the renal diet, or have completed DSMT and demonstrate a need for MNT to address their renal condition.

The memo did not include a list of covered diagnosis codes. You should check with your local Medicare carriers for specific guidelines.

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

Medicare will pay for MNT in any outpatient setting, including the physician's office, an independent dietitian's practice or a hospital outpatient department. Medicare will not pay when the services are provided to a patient during an inpatient stay in a hospital or a skilled nursing facility because fees to these facilities include MNT.

In offices that have a registered dietitian on staff, you should be aware that the dietitian cannot bill the MNT codes "incident to" the physician. Incident to refers to situations when a qualified nonphysician practitioner provides services that the physician might perform directly to the patient under the supervision of the physician. "The dietitians or nutritionists must have their own Medicare provider numbers," notes Catherine Trinidad, CPC, certified coder for Community Health Center Network, a group 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 form CMS-855I before billing for MNT services. The new specialty code for registered dietitians and nutrition professionals is "71." If the registered dietitian is employed by the physician's office, form CMS-855R should be completed for reassignment of benefits to the office.

Codes 97802 and 97803 have been assigned 0.46 RVUs for each 15-minute increment, with a resulting national (not adjusted for region) Medicare payment to the dietitian of $14.154 for each 15-minute increment. Code 97804 has an RVU of 0.18, resulting in a payment of $5.539 per patient for each 30-minute session. (If these reimbursement amounts appear less than normal, that is because CMS states that dietitians and nutritionists cannot bill the full amount listed in the physician fee schedule. They are paid at 85 percent of the amount or, if it is less, the actual charge for the MNT.)

Although MNT codes were first published in CPT 2001, some private insurers have not developed policies concerning when they will pay, Moore says. "Private payers will pay for many 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 should not be used for patients with feeding tubes or for those who are receiving intravenous parenteral nutrition. However, they can be used with private payers in most other scenarios requiring MNT in all age groups, from low-birthweight infants to elderly patients with chronic diseases. For example, a 4-year-old is brought to the physician's office. His parents are concerned that he is not eating well or growing at a normal rate. If extensive tests rule out other problems, the physician may refer the child and parents for MNT.

Note: The coverage decision memo can be accessed on the Web at http://www.hcfa.gov/coverage/8b3-ggg2.htm.