Pediatric Coding Alert

Since CPT Codes introduced a trio of new codes in 2001 to medical nutrition therapy (MNT), numerous specialties are reaping the benefits. Many pediatric offices are stuck in a rut, however, and could energize revenues with 97802-97804.

"Many practices completely forget about these codes, which can offer incredible benefits to obese and diabetic children," says Victoria Jackson, administrator and chief executive officer of Southern Orange County Pediatric Associates and owner and executive director of OMNI Management Inc., a medical practice management and billing company in southern California. Although pediatric practices can't take advantage of many internal medicine procedures, such as laser ablation, they should look at ways to generate non-E/M revenue. MNT is certainly one of the areas pediatricians should consider having staff offer, says Jackson, whose group is now creating an MNT program.

Before you assign these codes, spend 30 minutes acquainting yourself with the MNT pyramid. Start with a healthy dose of the credentials and qualifications necessary to report these codes. Follow with what the counseling entails. Make sure you have a solid base of medically necessary patient requirements and your carriers'coverage guidelines.

Who Can Use the Codes?

Underusing MNT codes may stem from not understanding the credentials necessary to use 97802 (Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes), 97803 ( re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes) and 97804 ( group [2 or more individuals], each 30 minutes). Unlike certain E/M codes that require physicians to perform the services, 97802-97804 are only for non-physician use. Depending on the payer, registered nurses (RNs) and nurse practitioners (NPs) can provide initial assessment and intervention (97802) as well as reassessment and intervention (97803-97804).

"Not all plans require the counselor to be a dietitian," Jackson says. For instance, Blue Cross/Blue Shield of Massachusetts permits NPs to bill MNT codes.

But other insurers may require the nonphysician practitioner to be a registered dietitian (RD) or certified nutrition professional. "An RD possesses nutrition training to address specific medical nutrition needs that may be beyond a nurse's or NP's scope," says Pat McKnight, MS, RD, LD, assistant nutrition professor for Mount Carmel College of Nursing and legislation chair for the Ohio Dietetic Association and the Ohio Nutritional Council in Columbus. So, before starting an MNT program, you should check with payers and state guidelines for credential requirements.

Of course, prior to billing MNT, your pediatrician will have to meet with the patient and recommend therapy. For this "referral" visit, you should use a preventive medicine counseling code (99401-99404, Preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure] ) to report anticipatory nutrition guidance or use another E/M code, such as an established patient office visit (99212-99215, Office or other outpatient visit for an established patient ), to describe an established problem requiring nutrition guidance. And, pediatricians often provide thorough individual or intervention nutritional counseling, McKnight says. Whenever your physician provides these services, make sure to report an E/M service, not an MNT code.

Do the Patients Have to Meet Any Requirements?

Due to the amount of E/M and other codes that address counseling concerns, you may wonder what makes 97802-97804 more palatable. Unlike the E/M counseling codes, which are to promote health and prevent illness, the MNT codes require an established illness, Jackson says.

Therefore, pediatric practices that want to use 97802-97804 should establish certain diagnostic criteria to admit children into a therapy program, she advises. For instance, the guidelines could require a specific percentage of body fat to admit a chronically obese patient. Thus, diagnosis codes 278.00 (Obesity, unspecified) and 278.01 (Morbid obesity) could identify potential candidates. For some payers, a child who has diabetes may have to exhibit signs of an out-of-control diet that is making the patient's condition unstable. A diabetes diagnosis, such as 250.83 (Diabetes with other specified manifestations; type I [insulin dependent type] [IDDM] [juvenile type], uncontrolled) would support admission to the program.

Other payers may consider nutrition counseling appropriate for any diabetes mellitus diagnosis in the 250.x series, such as 250.03 (Diabetes mellitus without mention of complication; type I [insulin dependent type] [IDDM] [juvenile type], uncontrolled) or 250.01 ( type I [insulin dependent type] [IDDM], not stated as uncontrolled).

Other diagnoses may also qualify for coverage. For instance, North Dakota Medicaid allows phenylketonuria (PKU) (270.1), anorexia nervosa (307.1), bulimia (307.51), hypertension (401.0-401.9) and chronic renal failure (585) diagnoses to support using MNT.

What Does the Trio Include?

The next logical step before implementing an MNT program is knowing what the agenda should include. After the pediatrician determines that a patient could benefit from nutrition therapy, the counselor should meet with the child to discuss his or her weight problem. If the doctor identifies the need at an office visit and the nonphysician practitioner (NPP) assesses the patient afterward, you may report both 9921x and 97802 because, by definition, the pediatrician and NPP are providing different services, Jackson says.

At the initial assessment and intervention, the NPP may establish several counseling tools, such as a daily journal, a diet and exercise plan, and a reward program. Due to the extensive review of dietary history, medications, social and economic influences, physician-ordered lab tests, and discussion of patient-accepted changes involved in the initial assessment, 97802 may take an hour to an hour and a half, McKnight says. For each 15 minutes the NPP spends face-to-face with the child discussing such topics, you should report one unit of 97802. For instance, if the initial assessment takes 90 minutes, you should assign 97802 x 6, she advises.

During reassessments, the provider will go over the material initiated at the 97802 visit. Depending on how long weight loss and diet modifications take, the NPPmay request that the child return for rechecks every few weeks. During the rechecks, the counselor could review the patient's diary, re-evaluate the diet and exercise plan, and hand out incentives for achieved goals, Jackson says.

The counselor usually spends a half hour on these follow-up visits, McKnight says. For each 15 minutes of individual reassessment and intervention, you should assign 97803. If the visit takes 30 minutes, as McKnight suggests, you should report 97803 x 2. If your practice provides group therapy (two or more individuals), report 97804 per 30 minutes. Pay attention to the time difference between individual and group counseling: one unit of 97803 for 15 minutes of individual counseling versus one unit of 97804 for 30 minutes of group counseling.

During the reassessment period, the pediatrician will probably recheck the patient's progress periodically, Jackson stresses, so you should report the physician's services with 9921x.

Will Payers Cover MNT?

Of course, your pediatricians will see this as an added benefit for their patients but may not consider it until they are sure payers will cover the service. "Many private insurers, such as individual Blue Cross Blue Shield plans, allow the CPT codes," McKnight says. But in Ohio, practices are struggling for coverage from Medicaid, she reports. When a payer refuses to cover MNT, such as Ohio Medicaid, she recommends using an E/M code. Although an office visit is an acceptable way to report counseling, payers that disallow 97802-97804 make gathering statistics on the use of these 2-year-old codes impossible, she says.

Some insurers may not cover 97802-97804 because they consider poor nutrition a behavior problem, Jackson says. So, the company's mental-health carve-out may exclude coverage of these codes. The plan may also consider the treatment of obesity a noncovered service. But don't give up yet your practice may charge the patient for the service because the MNT program would constitute an established noncovered service, Jackson says. Parents may see only the sweetness in a deal that helps their child develop proper eating habits, and they may overlook the additional fee. Whichever method you choose, you can know that your practice is offering a much-needed service in this overindulgent society.