Wednesday, August 24, 2011

CPT code - 97802, 97803, 97804, G0270, G0271, G0108, dx code

Diabetes Self-Management Training (DSMT)

CPT code G0108 – DSMT, individual session, per 30 minutes


CPT G0109 – DSMT, group session (2 or more), per 30 minutes


97802- Medical nutrition indiv in - average fee payment - $30 - $40

No specific diagnosis code Contact the local Medicare Contractor for guidance


Medicare beneficiaries diagnosed with diabetes Must be ordered by the physician or qualified non-physician practitioner treating the beneficiary’s diabetes


Up to 10 hours of initial training within a continuous 12-month period


Subsequent years: Up to 2 hours of follow- up training each year after the initial year


Copayment/coinsurance applies


Deductible applies



Diabetes self-management training services may be covered by Medicare only if the treating physician or treating qualified non physician practitioner who is managing the beneficiary’s diabetic condition certifies that such services are needed. The referring physician or qualified non physician practitioner must maintain the plan of care in the beneficiary’s medical record and documentation substantiating the need for training on an individual basis when group training is typically covered, if so ordered. The order must also include a statement signed by the physician that the service is needed as well as the following:


• The number of initial or follow-up hours ordered (the physician can order less than 10 hours of training);

• The topics to be covered in training (initial training hours can be used for the full initial training program or specific areas such as nutrition or
insulin training); and

• A determination that the beneficiary should receive individual or group training.

The provider of the service must maintain documentation in file that includes the original order from the physician and any special conditions noted by the physician. 



Beneficiaries Eligible for Coverage and Definition of Diabetes 

Medicare Part B covers 10 hours of initial training for a beneficiary who has been diagnosed with diabetes.

Diabetes is diabetes mellitus, a condition of abnormal glucose metabolism diagnosed using the following criteria;

* a fasting blood sugar greater than or equal to 126 mg/dL on two different occasions;

* a 2 hour post-glucose challenge greater than or equal to 200 mg/dL on 2 different occasions; or

* a random glucose test over 200 mg/dL for a person with symptoms ofuncontrolled diabetes. 



COVERED DIAGNOSIS CODES: 

250.00-250.93 Diabetes mellitus
648.00-648.04 Diabetes mellitus complicating pregnancy, childbirth, or the puerperium
648.80-648.84 Abnormal glucose tolerance complicating pregnancy, childbirth, or the puerperium
790.2 Abnormal glucose tolerance test

ICD-10-CM CODES; EFFECTIVE 10/01/2015 

E08.311-E13.9 Diabetes mellitus
E09.311-E09.36 Drug or chemical induced diabetes mellitus with ophthalmic complications
E09.40 Drug or chemical induced diabetes mellitus with neurological complications with diabetic neuropathy, unspecified
E09.42 Drug or chemical induced diabetes mellitus with neurological complications with diabetic polyneuropathy
E10.10-E10.9 Type 1 diabetes mellitus
E11.00-E11.9 Type 2 diabetes mellitus
E13.00-E13.9 Other specified diabetes mellitus
J45.20-J45.998 Asthma
O24.011-O24.33 Diabetes mellitus in pregnancy, childbirth, and the puerperium
O24.811-O24.93 Other pre-existing diabetes mellitus in pregnancy, childbirth, and the puerperium
R73.01 Impaired fasting glucose
R73.02 Impaired glucose tolerance (oral)
R73.09 Other abnormal glucose
R73.9 Hyperglycemia, unspecified


• Services covered include education, training and counseling on nutrition, foot care, exercise, and drug regimen monitoring.


• Providers of diabetes education and training services must be Certified Diabetes Educators per the American Diabetes Association criteria. 






Medical Nutrition Therapy (MNT) CPT codes


The list of Medicare telehealth services has been expanded to include individual MNT as described by HCPCS codes G0270, 97802 and 97803. Effective January 1, 2006, the telehealth modifiers “GT” (via interactive audio and video telecommunications system) and modifier “GQ” (via asynchronous telecommunications system) are valid when billed with these HCPCS codes. This expansion to the list of Medicare telehealth services does not change the eligibility criteria, conditions of payment, payment or billing methodology applicable to Medicare telehealth services

CPT 97802, 97803, 97804, G0270, G0271


Services must be provided by a registered dietitian or nutrition professional


No specific diagnosis code Contact the local Medicare Contractor for guidance


Certain Medicare beneficiaries diagnosed with diabetes, renal disease, or who have received a kidney transplant within the last three years


1st year: 3 hours of one-on-one counseling
Subsequent years: 2 hours



MEDICAL NUTRITION THERAPY (MNT)   CLINICAL NUTRITION THERAPY

Service          Time             CPT Code

Initial Assessment And Intervention

This Code Can Be Used Only Once A Year For First Appointment

Medical Nutrition Therapy (MNT) 15 minutes 97802

Initial Assessment and Intervention 15 minutes 97802

Face to Face with the Patient 15 minutes 97802


NOTE: CPT codes 97802 and 97803 should be unit priced; four units = 60 minutes, and six units = 90 minutes. Six or more units will be priced at six units For Insurance Claim use the term “Medical nutrition therapy,” which is another term for clinical nutrition therapy..

NOTE: CPT codes 97802 and 97803 should be unit priced; four units = 60 minutes, and six units = 90 minutes. Six or more units will be priced at six units.



Description:

Nutritional counseling/Medical Nutritional Therapy (MNT) is an important part of the prevention and treatment of many diseases and conditions. It consists of a nutritional assessment, the assignment of a specific diet, counseling services, and/or specialized therapies to treat an illness or condition. Nutritional counseling/MNT is covered when ordered by a physician and provided by a Registered Dietitian/Nutritionist to treat an illness or medical condition in which MNT is proven to be effective for treatment. 


Diabetes Management:

Visits for Nutritional Counseling/MNT are not counted as part of the visits for diabetes education as defined in the Diabetes Treatment Mandatebenefit. For information relating to the diabetic mandate, please refer to the policy titled: Diabetes Treatment Mandate.

For information relating to nutritional management of diabetes by a Certified Diabetes Outpatient Education (CDOE) specialist please refer to the Diabetes Self-Management Education Mandate.

Coding:

The following codes are covered only when services are provided by a Registered Dietician/Nutritionist for all lines of business:

97802 Medical Nutrition Therapy (MNT) 15 minutes 
97803 All Subsequent Individual Appointments 15 minutes 
97804 Initial Group Appointments 30 minutes or  Subsequent Group Appointments 30 minutes 


Six or more units will be priced at six units for CPT codes 97802 and 97803.
Three or more units will be priced at three units for CPT code 97804. 

Medical nutritional therapeutics codes (97802, 97803, S9470) may be billed when counseling patients on obesity or weight management. These codes are compatible with any diagnosis but are most intended for illness or disease-related diagnoses such as obesity or diabetes.


Use the suitable code from 97802–97804. These codes should be reported only for services provided by nutritionists. If a physician provides medical nutrition therapy, the E/M or preventive services codes should be usefulness. Private payers may also understand HCPCS digest S9452, S9465 or S9470 for a session of nutrition therapeutics provided by a nutritionist.


Medicare payment


Prior to 01/01/11:
Copayment/coinsurance applies
Deductible applies


On or after 01/01/11:
Copayment/coinsurance waived
Deductible waived


Payment for MNT Services


The contractor shall pay for MNT services 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 (DSMT) 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.

The contractor shall pay the lesser of the actual charge, or 85 percent 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. As required by statute, use this same methodology for services provided in the hospital outpatient department.


A. Payable Codes for MNT with Applicable Instructions

• 97802 - Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes. (NOTE: This HCPCS code must only be used for the initial visit.)

• This code is to be used only once for the initial assessment of a new patient. The provider shall bill all subsequent individual visits (including reassessments and interventions) as 97803. The provider shall bill all subsequent group visits as 97804.

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

• The provider shall bill this code for all reassessments and all interventions after the initial visit (see 97802). This code should also be used when there is a change in the patient’s medical condition that affects the nutritional status of the patient (see the heading, Additional Covered Hours for Reassessments and Interventions).

• 97804 - Group (2 or more individual(s)), each 30 minutes

• The provider shall bill this code for group visits, initial and subsequent. This code can also be used when there is a change in a patient’s condition that affects the nutritional status of the patient and the patient is attending in a group.

NOTE: The above codes can be paid if submitted by a registered dietitian or nutrition professional who meet the specified requirements; or a hospital that has received reassigned benefits from a registered dietitian or nutritionist. These services cannot be paid “incident to” physician services.



3 comments:

  1. Hi,
    I have found cpt code 97802 is very complicated and mostly insurances does not paid.
    http://www.medicalbillingcptmodifiers.com/

    ReplyDelete
    Replies
    1. They will pay normally as long as the dx is diabetes or kidney disease we have found.

      Delete
  2. Can you bill 97802 after you have billed for 97804 for a patient? so, patient is seen in group on Monday 97804 and returns on Friday for an individual session 97802? Or should the second session be billed as 97803 individual Follow Up?

    ReplyDelete

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