Enhancing Your Benefit
FAQs on the Medical Nutrition Therapy (MNT) Part B Benefit for Diabetes and Renal Disease
Note: some of the terms you may not be familiar with are defined in the Glossary of Terms.
Q1: What is the new MNT benefit?
Q2: Which Medicare beneficiaries can use the MNT benefit and are there eligibility criteria for beneficiaries to receive the MNT benefit?
Q3: What Medicare forms should be used by registered dietitians and nutrition professionals to become qualified Medicare providers?
Q4: If an enrolled Medicare provider works in a hospital setting or clinic, can they bill Medicare directly or not?
Q5. What should be your first step in communicating billing information to your hospital's billing department or office staff?
Q6: Can RDs bill for MNT on the same date of service as an MD visit?
Q7: In a clinic setting does the "incident to" requirement to have a physician present when the person is being seen, pertain to the MNT benefit?
Q8: Can the registered dietitian or nutrition professional bill Medicare for MNT for diabetes and renal disease (as defined by the statute) for some beneficiaries and use the usual and customary fee for others?
Q9: Does a registered dietitian or nutrition professional have to be a CDE or have any specialized training in diabetes to provide MNT for diabetes and non-dialysis kidney disease?
Q10: Does a beneficiary need a referral for MNT services?
Q11: Are there protocols that dietitians must follow in providing MNT?
Q12: What CPT (Current Procedural Terminology) codes are allowed for reimbursement of MNT?
Q13: What is the definition of an "episode of care"?
Q14: What will be the allotted MNT benefit if a beneficiary has both diabetes and renal disease?
Q15: Can RDs provide MNT services at renal dialysis facilities to qualifying Medicare beneficiaries with non-dialysis kidney disease?
Q16: What are the payment rates for MNT?
Q17: How can you learn more about the MNT benefits?
: What is the new MNT benefit?
A: As of January 1, 2002 registered dietitians or nutrition professionals (see CMS Transmittal AB-02-059 for definitions)(1), can directly bill their Medicare local carrier for MNT provided to beneficiaries with renal disease or diabetes (gestational, type 1 and type 2). The diagnostic criteria for diabetes is a fasting glucose = 126 mg/dl). Renal disease means chronic renal insufficiency, a reduction in renal function not severe enough to require dialysis or transplantation; end-stage renal disease when dialysis is not received (diagnostic criteria is the glomerular filtration rate (GFR) 13-50 ml/min/1.73m2); and the medical condition of a beneficiary for 36 months after a kidney transplant (criteria is the date of the kidney transplant) (1).
MNT services are defined in statute as "nutritional diagnostic, therapy, and counseling services for the purpose of disease management which are furnished by a registered dietitian or nutrition professional...pursuant to a referral by a physician..." (2)
Note: "MNT services are not covered for beneficiaries receiving maintenance dialysis for which payment is made..." (1)
: Which Medicare beneficiaries can use the MNT benefit and are there eligibility criteria for beneficiaries to receive the MNT benefit?
A: Medicare beneficiaries who have Part B Medicare services can use this service with a referral from their treating physician. Part B services are purchased by people eligible for Medicare and pertain to outpatient services. They pay a monthly premium for Part B coverage. Part A Medicare is for inpatient services and people eligible for Medicare Part A pay no fee for this service.
The eligibility criteria for Part B Medicare beneficiaries to receive MNT are for diabetes: 1) must be diagnosed with type 1, type 2 or gestational diabetes (defined in diagnostic criteria for diabetes is a fasting glucose = 126 mg/dl)(1); 2) must be referred for MNT by their treating physician.
The criteria for beneficiaries with kidney disease is: 1) diagnosis of renal disease, meaning chronic renal insufficiency; end-stage renal disease when dialysis is not received (diagnostic criteria of GFR 13-50 ng.min/1.73m2,); and the medical condition of a beneficiary for 36 months after a kidney transplant (criteria is the date of the kidney transplant); 2) must be referred for MNT by their treating physician.
: What Medicare forms should be used by registered dietitians and nutrition professionals to become qualified Medicare providers?
A: To become a Medicare provider and to bill Medicare directly, the provider must file an application to obtain a Medicare Provider Identification Number (PIN) number. This is CMS Form 855I, the Application for Individual Health Care Practitioners form. The specialty code for dietitians/nutritionists is 71. RDs in need of information about filing an application contact your local Medicare carrier. If the RD works for a hospital or clinic to which they will need to reassign their benefits, additional form(s) will need to be completed. For example, the health care facility may also require the RD to file the CMS Form 855 R, the Application for Individual Health Care Practitioners to Reassign Medicare Benefits form, with their local Medicare carrier. This form allows the dietitian or nutritionist to re-assign her/his Medicare reimbursement to the organization to whom the practitioner authorizes to bill Medicare on her/his behalf.
In addition, some RDs may need to complete CMS Form 855B, the Application for Health Care Suppliers that bill Medicare Carriers form. This is used by dietitians and nutritionists who form a group practice to enroll in Medicare and bill Medicare as a single supplier. Single supplier includes individuals, partnerships, groups, organizations, and corporations. Individuals must enroll individually and may enroll as a member of an organization. When joining an organization, the individual reassigns their benefits. If the dietitian's or nutritionist's employer (i.e., hospital) doesn't have a Part B billing number it must complete a CMS 855B to obtain a PIN.
To determine your local Medicare Carrier go to: www.cms.hhs.gov/providers/enrollment/contacts/. All of these forms are available and can be downloaded from the web site: www.cms.hhs.gov/providers/enrollment/forms/. .
: If an enrolled Medicare provider works in a hospital setting or clinic, can they bill Medicare directly or not?
A: The answer to this depends on the employment relationship and the type of relationship the system/program wants to set up with the provider. One important point to keep in mind about this benefit is that only Medicare carriers can pay claims for MNT. This means that providers of MNT can only submit claims on HCFA 1500 forms or the appropriate electronic format and all claims must be submitted to local Medicare carriers. Hospitals and related out-patient facilities may be more used to billing Medicare Fiscal Intermediaries and using different claim forms (UB-92 also called the HCFA 1450). So this might be a change for your health care facility. However, health care facilities are allowed to file claims with carriers on 1500 forms. CMS has indicated, "No claims for MNT are to be paid by (FIs).
: What should be your first step in communicating billing information to your hospital's billing department or office staff?
A: If you are in a health care facility, your best first step might be to sit down with a knowledgeable person from your billing office or administrative staff. Talk with this person(s) about the implications and benefits of the MNT benefit for your institution. Discuss how the billing office or administrative staff wants you to manage/direct the payments for your services, then determine which CMS forms each of you need to complete. Getting your facility to be willing to have you bill for MNT may require you to educate and convince several people.
Additional information on the Medicare Part B Coverage MNT Billing Guidelines and RDs Involvement in the Medicare MNT Benefit is available on the American Dietetic Association's web site at: http://www.eatright.org/gov. (Note: use of some areas on this site are for members only and require input of an American Dietetic Association membership number.)
: Can RDs bill for MNT on the same date of service as an MD visit?
A: Yes the RD can bill for MNT on a day that the person sees the MD. The only stipulation is that MNT cannot be billed or provided on the same day as DSMT.
: In a clinic setting does the "incident to" requirement to have a physician present when the person is being seen, pertain to the MNT benefit?
A: No. This is stated in the Program Memorandum AB-02-059 published on May 1, 2002. (1)
: Can the registered dietitian or nutrition professional bill Medicare for MNT for diabetes and renal disease (as defined by the statute) for some beneficiaries and use the usual and customary fee for others?
A: No. Medicare requires that if you become a Medicare provider that you bill Medicare for all covered Medicare services provided to Medicare beneficiaries. It is illegal to do otherwise. However, RDs can bill the patient or a secondary/supplemental insurer for non Medicare covered services i.e. MNT for hyperlipidemia. The RD who doesn't enroll as a Medicare provider cannot bill the Medicare beneficiary or the Medicare system for MNT for diabetes and renal disease. If the RD wants to see people who have Part B Medicare, but not bill Medicare for this service she must formally opt out of Medicare and enter into a private contract with each beneficiary. The opt out period lasts for two years. More information on this is available at www.eatright.com/members/provlinks.html.
: Does a registered dietitian or nutrition professional have to be a CDE or have any specialized training in diabetes to provide MNT for diabetes and non-dialysis kidney disease?
A: No. The regulations on MNT require that the provider be a registered dietitian or nutrition professional.
: Does a beneficiary need a referral for MNT services?
A: Yes, the beneficiary must have a referral for MNT from their treating physician. Treating physician is defined by Medicare as either the primary care provider or the specialist coordinating the diabetes care. CMS has indicated that "Non-physician practitioners cannot make referrals for this service."(1)
: Are there protocols that dietitians must follow in providing MNT?
A: Yes. CMS has stipulated that MNT be provided in accordance with "national accepted dietary or nutritional protocols for diabetes (type 1, type 2 and gestational) and non-dialysis kidney disease."
American Dietetic Association has published several protocols as American Dietetic Association Medical Nutrition Therapy Evidence Based Guides for Practice. The protocols currently available for purchase from American Dietetic Association as CD- ROMs. The following are now available: Diabetes Type 1 and Type 2, Gestational Diabetes, and chronic kidney disease, non-dialysis.
Practitioners can purchase available CD-ROMs by calling American Dietetic Association's Member Service Center at 800-877-1600 ext. 5000 or visiting American Dietetic Association's online catalog at www.eatright.com/catalog/. American Dietetic Association member price: $15.00 and non-member price: $25.00.
For more information and/or to purchase, visit American Dietetic Association website www.eatright.org/qm or send an email to email@example.com.
: What CPT (Current Procedural Terminology) codes are allowed for reimbursement of MNT?
A: The only CPT codes designated by CMS for MNT are:
97802 - initial assessment and intervention (individual/face-to-face with patient) - billable in 15 minute increments
-This code can only be used once per year for the initial assessment of a new patient. Code all subsequent visits as
97803 - re-assessment intervention and (individual/face-to-face with patient) - billable in 15 minute increments
-This code is to be used for all individual reassessments and interventions after the initial visit (97802)
97804 - group MNT (2 or more individuals) - - billable in 30 minute increments
-This code is to be used for all group visit - initial and follow-up
Note: These codes can only be paid if submitted by a registered dietitian or qualified provider. These services cannot be paid "incident to" physician services.
Note: When you provide the nutrition components within the initial 10 hours of the DSMT program, which is a required part of the program, or as part of DSMT follow-up, use the G codes for billing. If the referral from the treating physician is specific for MNT for diabetes and that is what you provide, then use the MNT CPT codes.
: What is the definition of an "episode of care"?
A: An episode of care is the period that begins with the initial assessment, follow up interventions and reassessment. The National Coverage Determination (NCD) defined the initial MNT benefit for diabetes and renal as 3 hours of service within a 12 month period and 2 hours for follow-up care within an episode of care. (2) The number of hours covered for renal disease are the same. Additional hours in the first 12 month period are considered to be medically necessary and covered if the treating physician determines there is a change in medical condition, diagnosis, or treatment regimen that requires a change in MNT and orders additional hours during that episode of care. A physician referral is required for each episode of care, eg. every year.
: What will be the allotted MNT benefit if a beneficiary has both diabetes and renal disease?
A: According to CMS, beneficiaries with both diabetes and renal disease (not on dialysis or within 36 months post transplant) can receive hours of MNT beyond what the NCD guidelines stipulate. According to the Program Memorandum AB-02-059 (1) "Additional hours of MNT services may be covered beyond the number of hours typically covered under an episode of care when the treating physician determines there is a change in diet necessary. Appropriate medical review for this provision should only be done on a postpayment basis. Outliers may be judged against nationally accepted dietary or nutritional protocols." The "progress notes" found in the American Dietetic Association's protocols can help RDs document beneficiaries' changes in behavioral MNT goals, and can be used to indicate the need for additional MNT visits.
: Can RDs provide MNT services at renal dialysis facilities to qualifying Medicare beneficiaries with non-dialysis kidney disease?
A: If the RD is an employee of a renal dialysis facility; the employee contract could potentially be modified to address the inclusion of Medicare MNT services in a facility that offers dialysis. Dietitians are encouraged to pursue these opportunities. Nutrition services provided to Medicare beneficiaries on dialysis are included in Medicare Part A and cannot be billed separately.
: What are the payment rates for MNT?
A: CMS has indicated, "Payment will be made under the physician fee schedule for dates of service on or after January 1, 2002, to a registered dietitian or nutrition professional that meets the above requirements. Deductible and coinsurance apply. As with the diabetes self-management training benefit, payment is only made for MNT services actually attended by the beneficiary and documented by the provider, and for beneficiaries that are not inpatients of a hospital or skilled nursing facility." "Pay the lesser of the actual charge, or 85% of the physician fee schedule amount when rendered by a registered dietitian or nutrition professional. Coinsurance is based on 20 percent of the lesser of these two amounts." (1)
According to information posted by American Dietetic Association at http://www.eatright.com/memberlogin.php, The final rule establishes payment values for codes 97802 and 97803 at .46 Relative Value Units (RVUs) per 15-minute increment and for group code 97804 at .18 RVUs per 30-minute segment. Using the 2002 CMS conversion factor and including the 20% patient co-pay, this translates to about $14.15 per 15 minute (or $56.62 for 60 minutes) for MNT provided by qualified dietitians for codes 97802 and 97803. For group MNT, using the 2002 CMS conversion factor and including the 20% patient co-pay, this translates to about $5.53 per patient for each 30 minutes (or $11.08 for 60 minutes per patient). There may be slight adjustments to these amount based on geographic practice cost indexes that CMS makes to the Medicare payment schedule.
: How can you learn more about the MNT benefits?
A: Review the Selected Resources to find out about additional resources on this topic area.
1. CMS Program Memorandum, Additional Clarification for MNT Services for Beneficiaries with Diabetes or Renal Disease. Published May 1, 2002. To review this document go to: www.cms.hhs.gov/manuals/pm_trans/AB02059.pdf then go to Program Transmittals and look for: AB-02-059.
2. Medicare Coverage Policy Decision: Duration and Frequency of the Medical Nutrition Therapy (MNT) Benefit (#CAG-00097N).