Part B Medicare Benefits for Medical Nutrition Therapy
FAQs on Coordination of the Medical Nutrition Therapy (MNT) and Diabetes Self-Management Training (DSMT) Part B Medicare Benefits Note: some of the terms you may not be familiar with are defined in the Glossary of Terms.
Q1: What does the National Coverage Determination (NCD) (1) have to do with the coordination of the Diabetes Self-Management Training (DSMT) and medical nutrition therapy (MNT) benefits? [note: DSMT is synonymous with diabetes self-management education (DSME)].
Q2: How will the MNT and DSMT benefits be coordinated as of the effective date of implementation of the NCD on October 1, 2002?
Q3: What are the number of hours allowed for initial DSMT and initial MNT?
Q4: What are the number of hours allowed for follow-up DSMT and follow-up MNT?
Q5: Is there a difference between MNT and the nutrition content provided in DSMT?
Q6: Is there any stipulation that DSMT must be provided before the MNT or visa versa?
Q7: Should the nutrition component provided within a DSMT program be billed or viewed any differently now that the MNT benefit is effective?
Q8: Can a registered dietitian who is one of the multi-disciplinary team members in an accredited DSMT program also provide and bill for MNT under the Medicare MNT benefit within the DSMT program?
Q9. Can a registered dietitian who is an approved Medicare provider with a PIN and who also is a multi disciplinary team member in an accredited DSMT program use her/his PIN to bill for DSMT?
Q10: Who makes the referral to initiate either the MNT or DSMT benefits?
Q11: What are some of the differences in the coding and billing requirements for either MNT or DSMT benefits?
Q12: What claims processing forms should be used for the DSMT and MNT benefits?
: What does the National Coverage Determination (NCD) (1) have to do with the coordination of the Diabetes Self-Management Training (DSMT) and medical nutrition therapy (MNT) benefits? [note: DSMT is synonymous with diabetes self-management education (DSME)].
A: A National Coverage Determination is the official statement of Medicare Reimbursement policy from Centers for Medicare & Medicaid Services (CMS). NCDs are published in the CMS Coverage Issues Manual and are subject to appeal if a party is dissatisfied with the determination. The NCD was published to accomplish several purposes. As required by the MNT final rule the NCD established the duration and frequency of MNT. Another purpose was to provide guidance for coverage of MNT and DSMT during the same period.
The NCD was published on February 28, 2002 and the effective date is October 1, 2002. Both the MNT final rule and the NCD must be read together to understand the legal requirements of the new MNT benefit. The final rule and the NCD complement each other, and when fully implemented, will coexist to describe the MNT benefit parameters and the coordination of benefits. The NCD also describes the differences between the MNT and the DSMT benefits and specifies that DSMT and MNT cannot be provided for on the same date of service day.
: How will the MNT and DSMT benefits be coordinated as of the effective date of implementation of the NCD on October 1, 2002?
A: These benefits are viewed as complementary benefits. The only stipulation will be that they may not be provided on the same date of service. They can, however, be billed on the same date of service.
: What are the number of hours allowed for initial DSMT and initial MNT?
A: The initial number of hours allowed for DSMT remains at 10 while the initial MNT benefit is 3 hours. So at a minimum, the qualified beneficiary, who meets the diagnostic criteria and medical necessity for both benefits can receive 10 hours of DSMT and also receive 3 hours of MNT as long as the services are not provided on the same date. They can, however, be billed on the same date. Thus, an eligible beneficiary may receive a total of at least 13 hours of initial service. Not all Medicare beneficiaries with a diagnosis of diabetes will qualify for both MNT and DSMT benefits.
The NCD states that qualifying registered dietitians or nutrition professionals may choose how many units are performed per day as long as all of the other requirements in the NCD and the MNT final rule (1, 2). The NCD states that additional hours of MNT can be covered if the treating physician determines 1) there is a change in medical condition, diagnosis, or treatment regimen that requires a change in MNT and 2) orders additional hours of MNT during the episode of care. (1)
: What are the number of hours allowed for follow-up DSMT and follow-up MNT?
A: As of October 1, 2002, the effective date for the implementation of the NCD, there will be no coordination of these benefits. They are complementary benefits. An eligible beneficiary with diabetes will be allowed up to 2 hours of follow-up DSMT annually and up to 2 hours of follow-up MNT annually. DSMT follow-up training, unlike the initial training, can be provided either individually or in a group, regardless of barriers to learning. The MNT and DSMT follow-up hours may be provided in any increments billable with the appropriate CPT codes (i.e. in half-hour increments for DSMT and quarter hour increments for individual MNT and half-hour increments for group MNT). Both services require a referral. Keep in mind that according to the NCD the treating physician can refer the beneficiary for additional hours of MNT. (1)
: Is there a difference between MNT and the nutrition content provided in DSMT?
A: Yes. MNT services are defined in the MNT statute as "nutritional diagnostic, therapy, and counseling services for the purpose of disease management which are furnished by a registered dietitian or nutrition profession and nutrition professionals enrolled as Medicare providers must also use "nationally recognized protocols such as those developed by the American Dietetic Association." (3) The DSMT program includes nutrition as one component of the curriculum content. The nutrition curriculum in the DSMT program must be consistent with the requirements in the National Standards for Diabetes Self-Management Education. (4)
The NCD describes the differences as follows: The DSMT benefit consists of ten different functional areas of which nutrition counseling is only one. The intent of DSMT is to provide overall guidance related to all aspects of the disease designed to increase the beneficiary's knowledge about the disease and how they can exercise control over their own health. MNT is described in the NCD as a more intensive nutritional counseling and therapy regimen that relies heavily on follow-up and feedback to the beneficiary to change their behavior over a period of time.
CMS's rationale for covering both DMST and MNT benefit is that the two benefits provide different behavioral modification techniques, which may prove to be complementary. The only stipulation is that they will not cover the services if they are provided for on the same date of service. This coverage policy was adopted to allow the beneficiary to receive the effect of reinforcement over a period of time.
: Is there any stipulation that DSMT must be provided before the MNT or visa versa?
: Should the nutrition component provided within a DSMT program be billed or viewed any differently now that the MNT benefit is effective?
A: No. The DSMT program should continue to bill using the G codes for all services provided through the program, including the nutrition component. The MNT benefit offers a completely distinct opportunity to provide and be reimbursed by Medicare for MNT services furnished to appropriately qualifying beneficiaries.
: Can a registered dietitian who is one of the multi-disciplinary team members in an accredited DSMT program also provide and bill for MNT under the Medicare MNT benefit within the DSMT program?
A. Yes. A Registered Dietitian who is a multi-disciplinary team member involved in providing the nutrition component of an accredited DSMT program may elect to enroll as a Medicare provider and provide MNT to qualified Medicare beneficiaries. With respect to MNT services, the registered dietitian, or the facility that bills on behalf of the registered dietitian, bills for the Medicare MNT covered services using the HCFA1500 form and the appropriate CPT codes for MNT services. Only registered dietitians or qualified nutrition professionals can become Medicare providers for the Medicare MNT benefit.
For the nutrition component of the DSMT program, the entity accredited as the DSMT program continues to bill Medicare using either a UB92 or a HCFA1500 form and the appropriate DSMT codes for all services covered by the DSMT program, which includes any nutrition training. MNT services and the nutrition component of a DSMT program remain distinct services even when a single registered dietitian provides both the MNT services and the nutrition component of a DSMT program. However, both services can be provided to eligible Medicare beneficiaries.
: Can a registered dietitian who is an approved Medicare provider with a PIN and who also is a multi disciplinary team member in an accredited DSMT program use her/his PIN to bill for DSMT?
A. Yes. It is stated in CMS program memorandum B0140, published on 6/15/01 about DSMT, that "all certified providers that provide other individual items or services [i.e. MNT] on a fee-for-service basis and that meet quality standards can receive reimbursement for diabetes training. Certified providers must be currently receiving payment for other Medicare services. The statute states that a 'certified provider' is a physician or other individual [i.e. RD] designated by the Secretary that, in addition to providing diabetes self-management services, provides other items for which payment may be made under title XVII [i.e. MNT] such as medical services or durable medical equipment, and meets certain quality standards. (5)
Accordingly, RDs who are enrolled with CMS to provide MNT can establish an accredited DSMT program, which operates as a distinct entity from a facility such as a hospital, and provide separate Medicare MNT services in the same location. The RD can use their PIN number to bill both MNT and DSMT services. The RD billing the DSMT services does not need to be the sole provider of all the DSMT services. It is important for the RD using her/his PIN to remember that his/her PIN will be used to report the program's income to the Internal Revenue Service. By using your Medicare MNT PIN that is linked to your social security number, you are assuming more personal liability. RDs will be personally taxed on income received from DSMT programs and realize other legal liabilities of the program.
If the RD is going to set-up an accredited DSMT program, the RD would enroll using the CMS855B (group form). This form requires the suppliers' tax identification number, e.g. the number the supplier uses to report tax information to the Internal Revenue Service. Because of the personal liability risk to the practitioner, RDs should consider the benefits of setting up alternative business arrangements, such as a limited liability partnership (LLP), incorporation or other arrangement. Consult a business advisor for more details on business arrangements. The tax identification number that is established through the business arrangement would then be listed on the enrollment form for the DSMT program.
: Who makes the referral to initiate either the MNT or DSMT benefits?
A: MNT may only be ordered by a physician and the physician must be the "treating physician." Meaning "the primary care physician or specialists coordinating care for the beneficiary with diabetes or renal disease." (2) DSMT may be ordered by either a physician or a qualified non-physician practitioner, such as a nurse practitioner or physician's assistant.
: What are some of the differences in the coding and billing requirements for either MNT or DSMT benefits?
A: The Medicare MNT regulations indicate qualifying registered dietitians or nutrition professionals must use the MNT CPT codes 97802, 97803, or 97804; 15-minute increments accepted for 97802 and 97803, 30 minute increments for 97804. DSMT requires use of G codes GO108 and GO109; 30 minute increments for both codes.
: What claims processing forms should be used for the DSMT and MNT benefits?
A: MNT claims must be billed using the HCFA1500 form. DSMT claims may be billed on either the UB92 or HCFA1500 form, depending on the type of entity that is the accredited DSMT program.
Additional information and interpretation of CMS regulations for MNT and DSMT is available from the Medicare carriers. Access this information from the carrier's web page. Carrier information can be accessed from CMS' web page http://cms.hhs.gov/providers/enrollment/contacts/.
1. Medicare Coverage Policy Decision: Duration and Frequency of the Medical Nutrition Therapy (MNT) Benefit (#CAG-00097N) Available at www.cms.gov/coverage/8b3-ggg.asp.
2. Final MNT Regulations. CMS-1169-FC. Federal Register, November 1, 2001. Department of Health and Human Services. 42 CFR Parts: 405, 410, 411, 414, and 415. Available at: www.eatright.org/cmsfinal110101.html.
3. CMS Program Memorandum, Additional Clarification for MNT Services for Beneficiaries with Diabetes or Renal Disease. Published May 1, 2001. Available at: www.cms.hhs.gov/manuals/pm_trans/AB02059.pdf.
4. Mensing C, et al.: National Standards for Diabetes Self-Management Education, Diabetes Care. 25 (Supp 1): S140-S147, 2002.
5. Expanded Coverage of Diabetes Out-Patient Self-Management Training, June 15, 2001. PM B-01-40. To review this document go to: www.cms.hhs.gov/manuals/pm_trans/B0140.pdf.