Dietitian Services: Medicare Nutrition Therapy Coverage

Does Medicare Cover a Dietitian Nutritionist?

Medicare started covering medical nutrition therapy (MNT) provided by a registered dietitian nutritionist (RDN) in 2002. This benefit is for Medicare recipients that have diabetes, non-dialysis kidney disease or have had a kidney transplant in the last 36 months.

Copay for Nutrition Counseling

Since 2011, Medicare considers nutrition counseling a preventive visit, so the patient pays $0. This is unlike most other non-preventive Medicare Part B services, in which the patient is responsible for a 20% coinsurance.

Is a Referral Required?

Unlike most commercial plans, Medicare does require a referral for MNT. The referral must be from a physician (MD or DO) and cannot be from any other provider type, such as a nurse practitioner (NP) or physician assistant (PA).

A new referral is required on a yearly basis. Centers for Medicare and Medicaid Services (CMS) specifically states “every calendar year a beneficiary must have a new referral for follow-up hours.” Note that this is a calendar year. Therefore, if a patient has a referral from December and is not scheduled until January, a new referral in the new year will be required.

The Medicare referral requirement is frankly quite burdensome on both the providing and referring provider and can create delays in patient treatment. I recommend not scheduling any Medicare patients for the first several weeks of the calendar year, if not longer, to ensure a correct referral is obtained, before the patient is seen.

In my office, towards the end of the calendar year, my assistant creates a list of all Medicare patients scheduled for the upcoming year with their scheduled appointment date. She creates tasks for herself in our electronic health record (EHR) to request the new referral on January 2nd or later. She can even create the fax ahead of time and schedule it to be sent at a later date using our electronic faxing service.

My assistant will then follow up with the request as needed. It is not uncommon for referring offices to initially send unacceptable referrals, as either the referring provider is an NP or PA or an acceptable diagnosis code is not listed. We may have to go back and forth with them multiple times before the referral is correctly sent.

My assistant does not close out her task in the EHR until we receive an acceptable referral. If necessary, she will have the patient get involved in obtaining the referral or postpone the appointment until an acceptable referral is received.

In summation, when receiving referrals for Medicare recipients, make sure it has the following:

Date that is in the same calendar year as services are being provided
Referring provider is an MD or DO
Diagnosis listed is either diabetes or chronic kidney disease and a corresponding ICD-10 code is included

Limit to the Number of Visits

There is a limit of three hours (12 units) for the first calendar year of nutrition counseling and two hours (8 units) for every subsequent year. Unused hours cannot be rolled over into the next year.

How To Bill Medicare for MNT

To bill Medicare for nutrition counseling, use CPT^Ⓡ codes 97802 and 97803. Code 97802 is used for an initial visit and 97803 is for follow up visits.

Make sure the referring physician is listed on the CMS-1500 form in box 17 and their NPI number is in 17b. If the NPI number is not on the referral, you can search online for the provider’s NPI number, as this is public information. Be sure to use their individual NPI number rather than the group NPI number of the organization they work for. The qualifier DN should also be listed before the provider’s name to denote that they are the referring provider (versus the ordering and supervising provider).

Only RDNs that are credentialed with Medicare can file a claim with them.

Additional Visits Using G0270 or G0271

Additional hours of MNT are covered if medically necessary and ordered by a physician. This does require a second referral from the physician. These additional visits are billed using HCPCS G0270 and G0271, with G0270 being individual counseling and G0271 being group counseling.

Per CMS, additional hours are considered medically necessary, “if the 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.”

chart with medical codes for addition Medicare MNT hours

Medicare Reimbursement Rates for MNT

Unlike with private payers, Medicare fee schedules are public information, which can be found using the CMS Search the Physician Schedule Look-Up Tool.

Be aware that dietitians only get paid 85% of the Medicare fee schedule.

Coverage from a Medicare Advantage Plan

Medicare Advantage plans are required to cover all services that Original Medicare covers, including MNT. While not typical, some Medicare Advantage plans may have coverage beyond Medicare guidelines, so additional diagnoses or a higher visit limit may be billable.

From my personal experience, Medicare Advantage plans generally pay more compared to Original Medicare.

Other Coverage for Diabetes through Medicare

In addition to MNT, Medicare beneficiaries also have a separate diabetes self-management training (DSMT) benefit. This is billed using HCPCS G0108 and G0109. MNT and DSMT cannot be billed on the same day.

While dietitians can provide DSMT, Medicare requires that this service be provided through an accredited diabetes program. Accreditation is a costly, laborious process and may be unrealistic and impractical for most private practice dietitians.

Chart of DSME CPT Codes that includes G0108 and G0109

Coverage for Other Medical Conditions

Medicare Coverage for Obesity

At this time, Medicare does not cover MNT for obesity. However, there is a separate benefit, known as Intensive Behavioral Therapy (IBT) for obesity. This is for beneficiaries that have a body mass index (BMI) of 30 or greater.

While this benefit cannot be billed directly by a dietitian, it can be furnished by an RDN and then billed “incident to” an acceptable provider type.

For more information, read this blog post: Procedure Codes G0447 & G0473: Billing for Intensive Behavioral Therapy for Obesity

Medicare Coverage for Prediabetes

Medicare does not currently cover MNT for prediabetes, but beneficiaries do have a once per lifetime benefit known as the Medicare Diabetes Prevention Program (MDPP). This is a 12 month class provided by specific MDPP suppliers that use a specific CDC-approved curriculum.

Beneficiaries must meet all of the following criteria to be eligible for the MDPP:

Have a BMI ≥ 25 or ≥ 23 if self-identified as Asian
Have at least one lab value indicating prediabetes in the last year
- A1c of 5.7-6.4%
- Fasting plasma glucose (FPG) of 110-125 mg/dL
- 2-hour post-glucose challenge test result of 140-199 mg/dL
Have no previous diagnosis of diabetes with the exception of gestational diabetes
Does not have end-stage renal disease (ESRD) at any point during the MDPP services period

MNT Act: The Future of Medicare and Nutrition Counseling Coverage

Unfortunately, the Medicare MNT benefits are quite limited. Despite evidence that MNT is effective for disease states beyond diabetes and kidney disease, these are currently the only diagnoses covered by Medicare.

The MNT Act is a bill originally introduced in 2020 that would help improve access to dietitian services. It would expand the MNT benefit to cover additional diagnoses, including:

Prediabetes
Obesity
Hypertension
Dyslipidemia
Malnutrition
Eating disorders
Cancer
Gastrointestinal diseases including celiac disease
Cardiovascular disease
HIV/AIDS
any other disease or condition causing unintentional weight loss

The MNT Act would also allow for additional provider types to write the referrals, including NPs, PAs, clinical nurse specialists, and clinical psychologists.

Let your congress members you want the MNT Act to be passed!

Summary

Medicare covers dietitian services with CPT codes 97802 and 97803 for patients with diabetes and chronic kidney disease. Getting a new referral every calendar year from the correct provider type is required for successful payment. If the MNT Act passes, many more diagnoses would be covered, therefore helping RDNs furnish care to more patients.