Pediatric Coding Alert

Use this action plan so you won't miss out on reimbursement

The number of diabetes cases continues to rise, so you can't afford to miss out on reimbursement for nutritional and educational services that your staff dieticians provide. As long as you closely adhere to five basic steps, you'll find fewer denials waiting for you.

A Michigan subscriber recently sent the following question to Pediatric Coding Alert: "We have access to medical nutrition therapy (MNT) here, as well as diabetes education, but not many diagnoses are covered. I'm wondering how pediatricians are able to collect payment for MNT that they provide to kids."

When your practice takes part in these prevention efforts by offering nutritionist- or dietician-run nutrition therapy sessions, here's how you can ensure that you collect reimbursement.

Step 1: Choose Between CPT and HCPCS Codes

When an individual nutritionist consults with a patient in a noncertified physician setting, you'll most likely report diabetic sessions with 97802-97804. But if your practice has an American Diabetes Association-approved program, you may also use Medicare-specific codes G0108-G0109, says Maureen Latanick, PhD, RD, CDE, a nutritionist with Millhon Medical Clinic in Columbus, Ohio.

Here's how: For noncertified programs, select the nutrition session code based on the patient's diagnosis and the number of individuals involved. Use 97802 (Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes) for initial medical nutrition therapy involving a single patient, Latanick says.

Report a follow-up patient session with CPT 97803 (... re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes), she says. For group sessions, assign 97804 (... group [2 or more individuals], each 30 minutes).

Example: After a pediatrician diagnoses a patient with diabetes and orders MNT, the practice's certified nutritionist meets with the patient for a 45-minute initial assessment and intervention. The patient later returns for a two-hour group session that involves re-assessment and intervention. You should report the initial session with three units of 97802 and the group follow-up session with four units of 97804. One unit of the individual code represents 15 minutes, and a group unit consists of 30 minutes.

To code ADA-certified diabetes self-management training (DSMT) sessions, determine how many patients attended the service. Code individual sessions with G0108 (Diabetes outpatient self-management training services, individual, per 30 minutes). When two or more patients attend the session, assign G0109 (Diabetes self-management training services, group session [2 or more], per 30 minutes).

Step 2: Report Under the Nutritionist's ID Number

Prompt payment for MNT sessions depends on avoiding one common filing mistake: reporting these sessions as incident-to. Because 97802-97804 are nutritionist-specific codes, you should not report these codes incident-to a physician, says Greg Avellana, a registered dietician (RD) for an Ohio physician's office. "Always use the nutritionist's PIN," he says.

Step 3: Verify Coverage Limitations

If you're using the correct MNT/DSMT code and associated PIN, but your payer is still denying claims, double-check the insurer's coverage limitations. Many insurers allow a one-hour initial MNT visit and two hours of follow-up after the initial visit in the first year. Other coverages vary.

Some insurers (such as certain First Health PPO plans) allow all of their patients (regardless of diagnosis) to see a nutritionist for up to $200 in benefits each year. After that, the visits must be deemed medically necessary, and the insurer will then pay just 80 percent of the nutritionist's fees, even if the RD is considered "in network."

Other insurers will cover 100 percent of medically necessary MNT or DSMT for certain diagnoses, so you should get your payers' policies in writing.

Ultimately, verifying the plan benefit design is the patient's obligation, and if the plan doesn't cover the service, the patient can be balance-billed for those services provided.

Step 4: Check Diagnostic Requirements

To ensure nutrition therapy coverage, check the documentation to ensure that the patient's diagnosis is listed as a covered condition according to the insurer's policy.  For example, Aetna covers MNT and DSMT for a range of diagnoses, including diabetes (250.00-250.93), anorexia (307.1), epilepsy (345.00-345.91) and malnutrition (263.0-263.9).

Aetna excludes MNT and DSMT coverage for ADD (314.00) and ADHD (314.01), and only covers the treatments for obesity (278.00-278.01) in certain circumstances. Other payers may have similar guidelines, which may be accommodated if your practice knows ahead of time and if there is an appropriate alternative. If your insurer does not cover the documented diagnosis listed in the patient's chart, let the patient or patient's family know up-front that the MNT may not be covered.

Step 5: Make Sure the Referral Is Clear

Many insurers, particularly HMOs, will not reimburse for MNT or DSMT unless the treating physician provides a written referral for the service. When you bill an HMO for nutrition counseling, make sure you have the certificate number of the referral, says Anne Riehl, RD, a registered dietician with Mid Ohio Nutrition in Columbus. If you bill a PPO, a physician referral should be sufficient, she says. 

Best practice: Keep a copy of the physician referral in your patient's file in case the insurer ever requests it.