Primary Care Coding Alert

Private-payers' rules vary from Medicare's

Is your family practice providing medical nutrition therapy (MNT)? If so, you'll need to know if you should report an office visit (99212-99214), MNT (97802-97804) or preventive medicine service (99401-99404) code for nutrition counseling.
 
Depending on the payer, any of these codes may apply. Coding experts offer the following advice regarding billing MNT services.

1. Check Your Plans' Credential Requirements

You should first check with payers and state guidelines regarding who can provide nutrition counseling. CPT's only rule is that nonphysicians use 97802 (Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes), 97803 (... reassessment and intervention, individual, face-to-face with the patient, each 15 minutes ) and 97804 (... group [2 or more individuals], each 30 minutes).
 
"Not all plans require the counselor to be a dietitian," says Victoria Jackson, executive director of OMNI Management Inc., a medical practice management and billing company in southern California.
 
Some insurers allow registered nurses (RNs) and nurse practitioners (NPs) to provide initial assessment and intervention (97802) as well as reassessment and intervention (97803) and group therapy (97804). For instance, Blue Cross/Blue Shield of Massachusetts permits NPs to bill MNT codes, Jackson says.
 
Medicare alert: But other insurers, such as Medicare, require that a registered dietitian (RD) or certified nutrition professional provide MNT. "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.

2. Report E/M, MNT for Same-Day Referral, Assessment

Before billing MNT, your FP has to meet with the patient and recommend therapy. For this "referral" visit, you should choose the appropriate E/M code that describes the service.
 
If your FP provides anticipatory nutrition guidance, 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] ...). When a visit involves nutrition guidance for an established problem, you should report an office visit ( CPT 99201 - 99215 , Office or other outpatient visit for the E/M of a new or established patient ...).
 
If the FP identifies the need for MNT at an office visit and the nutrition counselor assesses the patient afterward, you may report both the E/M service and 97802.
 
By definition, the physician and nonphysician provide different services, Jackson says. For payers that follow the National Correct Coding Initiative, you will need to append modifier -59 (Distinct procedural service) to 97802-97804 to identify the MNT as a distinct service from the E/M.
 
3. Know What Diagnoses Your Payers Accept

Even though CPT only restricts 97802-97804 to patients who have an established illness, insurers' medical-necessity requirements vary. To ensure coverage for MNT, you should check payers' policies before enrolling a patient in a program.
 
Some payers may cover MNT for a variety of diagnoses. 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. Other plans also extend MNT coverage to patients who have obesity (such as 278.00, Obesity, unspecified; or 278.01, Morbid obesity).
 
But other plans restrict MNT payment to patients who have uncontrolled diabetes. For these policies, a child who
exhibits signs of an out-of-control diet that makes the patient's condition unstable (such as 250.83, Diabetes with other specified manifestations; type I [insulin dependent type] [IDDM] [juvenile type], uncontrolled) would meet medical-necessity criteria, Jackson says.
 
Other insurers may cover MNT for a wider range of diabetes diagnoses. For example, Medicare considers nutrition counseling appropriate for any diabetes mellitus diagnosis in the 250.xx series, as well as for gestational diabetes (648.8x, Other current conditions in the mother classifiable elsewhere, but complicating pregnancy, childbirth or the puerperium; abnormal glucose tolerance).
 
Medicare also offers 97802-97804 coverage for patients who have chronic renal insufficiency (585) or have received a kidney transplant (V42.0, Organ or tissue replaced by transplant; kidney) within the past 36 months.

4. Consider E/M for MNT Noncoverage

When a payer doesn't accept 97802-97804, you may substitute an E/M code. "Many private insurers, such as individual Blue Cross Blue Shield plans, allow the MNT codes," McKnight says. But for insurers that don't recognize 97802-97804, such as Ohio Medicaid, McKnight recommends billing an E/M code, such as 99212-99215.
 
An office visit is an acceptable way to report counseling. But reporting an E/M code instead of 97802-97804 leads to inaccurate statistics on MNT use, McKnight says.
 
Some experts caution against using office visit codes in place of MNT codes. You should always use codes based on their intended purpose, says Carol Sissom, CPC, a senior healthcare consultant at Health Care Economics Inc., a coding and practice management firm in Indianapolis. Codes 97802-97804 describe treating a condition preventively (through counseling and intervention), Sissom says. E/M codes represent treating a condition in a scientific approach (history, exam, medical decision-making).

5. Weigh Incident-To Requirements

Before deciding to use an office code for nutrition counseling, you should check payer's incident-to rules. Some private insurers may allow nutritionists to bill incident-to the supervising physician, just as an NP would. Others may follow Medicare's rules and require RDs to use their own personal identification numbers.
 
Remember that if a plan excludes MNT coverage, you may charge the patient for the service. The MNT program would constitute an established noncovered service, Jackson says.