Part B Medicare Benefits for Medical Nutrition Therapy

Covered MNT

Type 1 diabetes, Type 2 diabetes, gestational diabetes; non-dialysis kidney disease, and post kidney transplants

Practice Settings

• Practice settings (e.g., private practice, physician offices, ambulatory clinics); hospital outpatient departments; other outpatient settings.

• Excluded: inpatient hospital setting; skilled nursing facilities.

Medicare MNT Benefit and Diabetes Self
-Manage-
ment Training Benefit

• Through the National Coverage Determination (NCD) decision, CMS indicated the Medicare MNT benefit basic coverage (year 1) = 3 hours. CMS indicated "an episode of care typically includes 1 hour of initial assessment and four 30 minute follow-up interventions during the first year." Additional hours 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. Follow-up (year 2) = 2 hours
  
  
• Effective October 1, 2002, Medicare will cover DSMT (Diabetes Self-Management Training) and MNT in initial and subsequent years without decreasing either benefit as long as DSMT and MNT are not provided on the same date of service.
  
  
• Until October, the provisions of the final regulation are in effect regarding coordination of MNT and DSMT.

Registered dietitian or nutrition professional who meet all the following criteria:

• BS degree in nutrition or dietetics.

• Completion of 900 hours of supervised dietetics practice.

• Licensed or certified as dietitian or nutrition professional by State in which services are performed (if State does not provide licensure or certification, meets other criteria established by Secretary).

• Grandfathers dietitian, nutritional professionals licensed or certified as of 12/21/00.

• To clarify which forms to complete, RDs could contact their Medicare carrier and describe their practice settings (and location of) in which MNT benefit is furnished, so carrier can determine required provider forms to complete.
  
  
• To enroll, complete and submit CMS Form 855 I, Application for Individual Health Care Practitioners form.
  
  

--Local Medicare carrier; carriers' names, addresses, phone numbers, etc. on CMS' web page www.hcfa.gov/Medicare/enrollment/contacts

--CMS' web page www.hcfa.gov/Medicare/enrollment

--American Dietetic Association's web page www.eatright.com/members/statecarriers

--Some carriers may request copy of state license, registration certificate, or other proof of required qualifications.

• Depending on practice setting and employment relationship, RD may also need to complete:

• CMS 855 R Application for Individual Health Care Practitioners to Reassign Medicare Benefits form
  
  
• CMS Form 855 B Application for health Care Suppliers that Bill Medicare Carriers form

• Upon enrollment, RD will receive PIN, which is used on MNT claims. RD may be required to have a different PIN for:
  
  
  • Each practice setting situated in different fee schedule areas.
    
    
  • Each practice setting that is under the jurisdiction of a different carrier.
    
    
  • RDs may practice in a group. In this case the group must obtain a PIN in addition to each individual RD obtaining his/her own PIN.
    
    
• Medicare carrier uses these PINs in its accounting system to insure that: payment amounts are correct; payment is sent to the correct recipient (for tax reasons, among others) (e.g., RD as recipient vs. hospital as recipient).

Physician Referral

• Physician's referral for MNT is required:

• Physician can be treating physician or specialist who is treating beneficiary.

• Referral must indicate the order for MNT, beneficiaries' diagnosis (related to covered MNT benefit), physician's Unique Physician Identification Number (UPIN) and referral must be signed by physician.
  
  
• Documentation by RD of furnished MNT (initial and follow-up MNT) in beneficiary's medical record.

MNT Protocols

• When furnishing the MNT benefit, the final regulations state recognized protocols, such as those developed by the American Dietetic Association.

• The guides are now available for purchase on CD-Rom from American Dietetic Association.

CPT Codes for MNT benefit

• CPT Code 97802: MNT, initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes.

• CPT Code 97803: MNT re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes.
  
  
• CPT Code 97804: Group MNT (2 or more persons), each 30 minutes. These time-based MNT-specific CPT codes are listed once on the claim, but multiple units of code may be entered.

UN-Adjusted Medicare Allowed Reimburse-
ment Rates

CMS indicated Medicare will, "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."

Allowed payment rates have been established under the physician's fee schedule. The RD payment amount, 85% of the physician amount, without the geographic adjustment factor is:

• MNT CPT Code 97802 - $14.15 per 15 min. unit = $56.60 per hour (= 4 units)
• MNT CPT Code 97803 - $14.15 per 15 min. unit = $56.60 per hour (= 4 units)
• MNT CPT Code 97804 - $5.539 per 30 min. unit = $11.08 per hour (= 2 units)

Medicare reimburses 80% of the approved amount after the beneficiary has reached his/her annual $100 deductible. Remaining 20% of the approved amount, known as coinsurance, is the amount the beneficiary pays out-of-pocket.

• CMS applies a geographical adjustment factor (GAF) to the MNT rates in regions of country; thus, rates may vary from one region to another.
  
  
• Refer to American Dietetic Association's web site for GAFs and the adjusted MNT rates.

• RD must be Medicare provider to submit MNT claim for Medicare reimbursement.
  
  
• Beneficiary must have Part B insurance.
  
  
• MNT must be billed on HCFA 1500 form (can be purchased at office supply stores)

• Key data elements required on claim (but not limited to): Beneficiary information (including Medicare ID number); RD's name and Medicare PIN; referring physician's name and UPIN; RD's usual and customary MNT fee; CPTcode and number of units of code billed; ICD-9 diagnosis code(s); place of service code; dates of service; and beneficiary's signature *.

* In lieu of signing claim, beneficiary may sign a statement that is retained in provider's file. Patient's signature authorizes release of medical information necessary to process claim. "Signature on file" is then printed on claim.

• Provider must send MNT claim to the local Medicare carrier.
  
  
• Carrier reimburses the provider directly for MNT services rendered.

• RDs should establish a fee schedule for their MNT services.

A fee schedule should be used for all patients, including Medicare beneficiaries.

• RD who is Medicare provider charges beneficiary her/his usual and customary MNT fee.
  
  
• A beneficiary may have more than one type of insurance or coverage that will pay for services and procedures before, or along with, Medicare. The RD or hospital billing department must determine if a private insurance plan should be billed first before Medicare. Here Medicare is the secondary insurer.
  
  
• If no other insurance exists, and beneficiary qualifies, RD bills Medicare and "accept assignment" with regard to payment for MNT. Accepting assignment means:

• RD must accept Medicare approved payment as payment in full for MNT.
  
• RD must collect the co-payment and any unmet deductible from beneficiary.

• RD cannot bill beneficiary, or his/her secondary insurance for difference between RD's usual and customary fee and Medicare's approved payment amount.
  
• If the beneficiary has secondary insurance, that policy may cover Medicare deductible and/or coinsurance amounts

• Medicare Part B cannot be billed for non-covered MNT, nor can RD bill Medicare for non-covered MNT as "incident to physician's services".
  
• Only the client may be billed for MNT that is not currently covered under Medicare Part B.
  
• If client has secondary insurance, he/she may submit claim to insurance; plan may/may not cover the MNT.

• If RD does not become Medicare provider, she/he cannot furnish the covered MNT benefit to Medicare beneficiaries

• In this case, RD should refer beneficiary to RD who is a Medicare provider.

• RD who does not enroll to become Medicare provider cannot bill the Medicare beneficiary or Medicare.
  
  
• If RD still wishes to furnish MNT for diabetes or non-dialysis kidney disease to Medicare beneficiaries, RD must opt out of Medicare by entering into a private contract with each beneficiary:

• CMS delineates regulations for opting out.
  
  
• Opt out period is for two years.
  
  
• RD must fully understand all ramifications of opting out.
  
  
• The American Dietetic Association's web page includes additional details on opting out; Medicare carrier's web pages may also provide opt out information.