CPT CODE 97802 – Medical nutrition therapy;

by | Jul 10, 2021 | CPT modifiers

CPT Code Description


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

General Information


This PM informs the FIs of a change in payment policy regarding Medical Nutrition Therapy. Change Requests (CRs) 1905 and 2142 stated that MNT cannot be billed to FIs. After reviewing this policy, CMS has determined that MNT services can be billed to FIs when performed in an outpatient hospital setting. This PM also announces two new additional codes that have been developed for MNT services when there is a change in condition of the beneficiary. Currently, there is another CR (2373) that is being developed simultaneously that contains information on MNT.

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Billing Requirements CPT 97802

This service will be billed on the CMS-1450, or its electronic equivalent, but will not change the enrollment requirement for dieticians/nutritionists. The cost of the service is billed under revenue code 942 in FL 42. The provider will report CPT codes in FL 44, and the definition of the code in FL 43.

The applicable bill types are 13x, 14x, 23x, 32x, and 85x.

Payment for MNT

Use the condensed Physician Fee Schedule to make payment. Pay the lesser of the actual charge, or 85 percent of the fee schedule amount. Coinsurance is based on 20 percent of the lesser of these two amounts.

MNT services have been covered by Medicare beginning with dates of service January 1, 2002, and after. Payment will be made under the following codes:

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

This code is to be used only once a year, for initial assessment of a new patient. All subsequent individual visits (including reassessments and interventions) are to be coded as 97803. All subsequent Group Visits are to be billed as 97804.

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

This code is to be billed for all individual 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).

Policy Statement

Obesity screening and counseling Screening and counseling for obesity and counseling for a healthy diet are covered under the Patient Protection and Affordable Care Act (PPACA) otherwise known as health care reform (HCR).

The suggested coding for obesity screening and counseling includes 97802-97804, 99078, 99401-99404, 99411-99412, G0447 or S9470 as preventive with E66.9 or E66.01 (ICD-10- CM).

The suggested coding for counseling for a healthy diet includes 99401-99404, 99411-99412, 99078, 97802-97804, G0447, S9452, S9470 as preventive with Z71.3 (ICD-10-CM).
Refer to the information below for screening and other services not subject to PPACA. The outline reviews the following seven categories as they relate to coverage for services related to obesity, weight management, nutrition and physical activity counseling.

  1. Diagnosis Codes
  2. Procedure/Service Codes
  3. Eligible Providers
  4. Weight Loss Programs
  5. Weight Loss Drugs
  6. Physical Activity
  7. Surgery

Diagnosis Codes

The physician determines if the patient meets the criteria to be classified as obese. If the patient meets those criteria, two specific obesity diagnosis codes
may be used:

  1. E66.9 (ICD-10-CM)
  2. E66.01 (ICD-10-CM)
    In addition to the two specific obesity codes, the provider may also bill for obesity or weight management counseling with routine diagnosis codes such as:
  3. Z71.3 (ICD-10-CM)
  4. Z00.00 (ICD-10-CM)

The obesity diagnosis codes of E66.9, E66.01 and code Z71.3 will cause claims to pay according to the illness portion of the patient’s contract. All Blue Cross contracts have benefits for illness-related services. If the claim is submitted with a routine medical exam code of Z00.00, it will pay based on the routine benefits, if any, are provided by the patient’s contract. Some contracts exclude routine benefits.
Claims may be submitted for obesity, weight management, nutrition counseling etc. with the diagnosis of the underlying symptom that brought the patient to the provider. For example, the claim may be submitted with a diagnosis of elevated blood cholesterol, shortness of breath or diabetes. These claims will process according to the medical illness benefit.

Procedure/Service Codes

Services for obesity/weight management counseling may be billed under E/M codes (99201-99215) provided that those services meet the components of an E/M service. These E/M codes are compatible with all causes, illness or routine related, and will pay according to the diagnosis submitted.

Claims may also be submitted as preventive counseling (99401- 99404). These codes, however, are only compatible with routine diagnosis codes. Claims submitted with these procedure/service codes and a routine diagnosis code will process according to the patient’s preventive benefit, provided the patient has coverage for preventive services. If CPT codes 99401-99404 were submitted with a diagnosis of obesity the claim would reject because the service was incompatible with the diagnosis.

Medical nutritional therapy 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 appropriate or intended for illness or disease-related diagnoses such as obesity or diabetes.

Code 97804 is nutritional therapy in a group setting. Group therapy services are generally only covered when submitted with diagnosis codes for anorexia, bulimia, diabetes, congestive heart failure and some maternity diagnosis codes. Outpatient hospital eating disorder services are billed under revenue code 0942 and procedure codes 97802, 97803 and 97804.

Nutritionists, Dietitians, Dietitian/Nutritionist and otherProviders For many lines of business, Blue Cross pays Minnesota licensed nutritionists, licensed dietitians and registered dietitians directly for services submitted with an eating disorder ICD-10-CM diagnoses F50.00 F50,2 and F50.29. The provider may submit using procedure/service codes S9470, 97802, 97803 or 97804 based on the service provided. No referral is necessary for the highest benefit level. Some self-insured plans, however, may exclude coverage by a dietitian, so benefits should be verified.

Licensed dietitians and licensed nutritionists can bill for procedure/service codes S9470, 97802, 97803, and G0447 for diagnosis codes other than eating disorders. Services provided by licensed dietitians and nutritionists must be submitted to Blue Cross using the provider number or NPI of an eligible medical clinic or hospital. The individual provider number or NPI of the licensed dietitian or licensed nutritionist must also be submitted on the claim. Registered dietitians or Dietitian/Nutritionists billing for services outside of behavioral health diagnosis codes will have those claims denied unless the services are submitted under the
individual provider number of a supervising physician. The –U7 modifier (Physician extender) should also be submitted.

Health educators and exercise physiologists are not recognized as eligible providers and their services will be rejected if received by Blue Cross.

Physical Activity

There are no procedure/service codes specifically for physical activity counseling. Providers typically bill counseling services for physical activity as an E/M service (99201-99215) provided that the counseling meets the components of an E/M service. There is no specific diagnosis code for physical activity counseling.
Exercise classes (S9451) are generally non-covered.

The provider may also submit codes for preventive counseling (99401-99404). These codes however, are only compatible with routine diagnosis codes. Claims submitted with these procedure/service codes and a routine diagnosis code will process according to the patient’s preventative benefit, provided the patient has coverage for preventative services. Services billed by a personal trainer or an exercise physiologist are not covered. Claims for their services will be denied as an ineligible provider, regardless of the procedure/service code and diagnosis code submitted.

Surgery

Blue Cross has a detailed medical policy, IV-19, regarding provider and patient eligibility criteria for obesity surgery. Some groups exclude coverage for obesity surgery in their contracts. Preauthorization is highly recommended.

Overview

Section 1861(s)(2)(V) of the Social Security Act authorizes Medicare Part B coverage of medical nutrition therapy services (MNT) for certain beneficiaries who have diabetes or a renal disease. Regulations for medical nutrition therapy (MNT) were established at 42 CFR §§410.130 –410.134. The MNT national coverage determination (NCD) establishes the duration and frequency limits for the MNT benefit and coordinates MNT and diabetes outpatient self-management training (DSMT) as a national coverage determination.

Guidelines

Basic coverage of MNT for the first year a member receives MNT with either a diagnosis of renal disease or diabetes as defined in 42 CFR §410.130 is three hours of administration. Also, basic coverage in subsequent years for renal disease or diabetes is 2 hours. The dietitian/nutritionist may choose how many units are administered per day as long as all of the other requirements in the MNT NCD and 42 CFR §§410.130-410.134 are met. Pursuant to the exception in 42 CFR §410.132(b)(5), additional hours are considered to be medically necessary and covered if the treating physician determines that there is a change in medical condition, diagnosis, or treatment regimen related to diabetes or renal disease that requires a change in MNT and orders additional hours during that episode of care.

If the treating physician determines that receipt of both MNT and DSMT is medically necessary in the same episode of care, Medicare will cover both DSMT and MNT initial and subsequent years without decreasing either benefit as long as DSMT and MNT are not provided on the same date of service. The dietitian/nutritionist may choose how many units are performed per day as long as all of the other requirements in the NCD and 42 CFR §§410.130-410.134 are met. Pursuant to the exception in 42
CFR 410.132(b)(5), additional hours are considered to be medically necessary and covered if the treating physician determines that there is a change in medical condition, diagnosis, or treatment regimen related to diabetes or renal disease that requires a change in MNT and orders additional hours during that episode of care.

Section 105 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) permits Medicare coverage of Medical Nutrition Therapy (MNT) services when furnished by a registered dietitian or nutrition professional meeting certain requirements. The benefit is available for beneficiaries with diabetes or renal disease, when referral is made by a physician as defined in §1861(r)(l) of the Act.

Documentation/Billing:

  • Documentation must support the medical necessity of the service provided
  • Per CPT Guidelines Time must be documented in medical record
  • For initial visit the referring physician should be noted in the RD’s documentation
  • ALL patients presenting to the registered dietician (RD) for nutritional counseling should reference the appropriate code listed above.
  • The RD will need to indicate on the charge ticket how many times 97802/97803 should be billed. These codes are billed for each 15 minutes that is spent with the patient.
  • For example, if the dietician saw the patient for 1 hour, 97802 would be billed with a quantity of 4.
  • This can be noted on the ticket by putting “x 4” next to the code.
  • ALL charges should be submitted with the RD as the billing provider unless otherwise specified on the Managed Care Matrix

Medicare MNT Requirements:

Medicare Provides coverage of MNT services when the following general coverage conditions are met:

  • The beneficiary has diabetes or renal disease
  • The treating physician must provide a referral and indicate a diagnosis of diabetes or renal disease. A treating physician means the primary care physician or specialist coordinating care for the beneficiary with diabetes or renal disease (non-physician practitioners cannot make referrals for this service)
  • The number of hours covered in an episode of care may not be exceeded unless a second referral is received from the treating physician
  • MNT services may be provided either on an individual or group basis without restriction
  • MNT services must be provided by a registered dietitian, or a nutrition professional who meets the provider qualification requirements, or a “grandfathered” dietitian or nutritionist who was licensed as of December 21, 2000.
  • For a beneficiary with a diagnosis of diabetes, DSMT and MNT services can be provided within the same time period, and the maximum number of hours allowed under each benefit are covered. The only exception is that DSMT and MNT may not be provided on the same day to the same beneficiary.
  • For the beneficiary with a diagnosis of diabetes who has received DSMT and is also diagnosed with renal disease in the same episode of care, the beneficiary may receive MNT services based on a change in medical condition, diagnosis, or treatment.

The following CMS-1500 Claim Form instructions relate to medical nutrition therapy:

Field No. Name Entry
24G Days or Units Enter:
* 97802, not more than 8 units per year.
* 97803, not more than 4 units per day.
* 97804, not more than 4 units per day.

COVERAGE CRITERIA

Paramount considers medical nutritional therapy medically necessary for chronic disease states in which dietary adjustment has a therapeutic role, when it is prescribed by a physician and furnished by a qualified provider (e.g., registered dietician and licensed dietitians) following these parameters for the initial year of therapy:

  1. Initial assessment visit (97802)
  2. Follow-up intervention visits (97803, 97804)
  3. Reassessments as necessary during 12-month episode of care to assure compliance with dietary plan. (97803, 97804)
  4. 3 hours maximum in 1st year
    The only providers that should submit claims for medical nutrition therapy codes are registered dietitian nutritionists and licensed dietitians. Other qualified health care professionals may provide medical nutrition therapy; however, they must submit a claim for an evaluation and management service. For services of a dietitian who is employed by a hospital and is practicing in a hospital setting, payment is made only to the hospital. Medical nutrition therapy is not to be confused with diabetes self-management training (G0108-G0109). These are separate services, and providers are not to provide both these services on the same date of service to a member.
    HMO, PPO, Individual Marketplace, Elite/ProMedica Medicare Plan.

Paramount considers medical nutritional therapy medically necessary for chronic disease states in which dietary adjustment has a therapeutic role, when it is prescribed by a physician and furnished by a qualified provider (e.g., registered dietician and licensed dietitians) following these parameters for follow-up therapy:

  1. Additional hours permitted if treating physician determines a change in medical condition, diagnosis or treatment regimen that requires a change in MNT. (G0270-G0271)
  2. Documentation should support the patient’s diagnosis of the specific condition, along with the referral from the physician managing the patient’s condition. The documentation should also include a comprehensive plan of care, individualized assessment, and education plan with outcome evaluations for each session, as well as referring physician feedback. There should be specific goals, evaluations, and outcome measures for each session documented within the patient’s records.
  3. 2 hours maximum per calendar year in subsequent years Procedures 97802-97804, G0270 and G0271 are covered and do not require prior authorization.
    Procedures S9445, S9446, S9449, S9452 and S9470 are non-covered services.

Advantage

Procedures 97802-97804 may be utilized for medical nutritional therapy.
Procedures S9452 and S9470 may be utilized for prenatal nutritional counseling.
Procedures G0270, G0271, S9445, S9446, and S9449 are non-covered services.

CODING/BILLING INFORMATION
The appearance of a code in this section does not necessarily indicate coverage. Codes that are covered may have selection criteria that must be met. Payment for supplies may be included in payment for other services rendered.