Primary Care Coding Alert

Medicare will cover MNT and DSMT--but you must meet these requirements

With the number of diabetes cases consistently on the rise, you can't afford to miss out on reimbursement for nutritional and educational services that your staff dieticians provide.

On any given day, nearly half the patients at Montefiore Medical Center in the Bronx -are there for some trouble precipitated by- diabetes, according to a recent report in The New York Times titled -Diabetes and Its Awful Toll Quietly Emerge as a Crisis.- And nutrition and diabetes education is the key to preventing further disease-related complications.

-Nutritional and diabetes education alone lowered our patients- A1c by almost 1 percent without changing medication regimens,- says Reinhard Wolfgang Beel, CEC, business manager at Cumberland Valley Endocrinology Center LLC in Carlisle, Pa.

When your practice takes part in these prevention efforts by offering nutritionist- or dietician-run diabetes sessions, you can ensure your physician receives Medicare payment if you take these steps:

Step 1: Choose Between CPT and HCPCS Codes

When an individual nutritionist consults with a patient in a non-certified physician setting, you-ll most likely report diabetic sessions with 97802-97803. -But if your practice has an American Diabetes Association-approved program, you may also use G0108-G0109,- says Maureen Latanick, PhD, RD, CDE, a nutritionist with Millhon Medical Clinic in Columbus, Ohio.

Here's how: For non-certified programs, select the nutrition session code based on the patient's status and the 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 (MNT) involving a single Medicare diabetic patient,- Latanick says.

Report a follow-up patient session with 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 physician diagnoses a patient with diabetes and orders MNT, the practice's 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 Number

Prompt payment of 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 Grand View Family Practice in Columbus, Ohio. -Always use the nutritionist's PIN,- he says.

Exception: In a recognized program when submitting a DSMT code, you should instead use the group's number, Avellana says. -Once again, the service--G0108 or G0109--would not be incident-to.-
 
Step 3: Verify Frequency Coverage

If you-re using the correct MNT/DSMT code and associated PIN, but Medicare is still denying claims, double-check your carrier's coverage limitations. -Medicare allows a one-hour initial MNT visit and two hours of follow-up, following the initial visit in the first year,- Beel says. Carriers cover two hours of follow-up MNT annually.

You can expect lengthier coverage of DSMT, however. In addition to MNT hours, -Medicare allows a one-hour initial DSMT visit and 10 hours of group sessions- in the first year, Beel says. In subsequent years, -An eligible beneficiary with diabetes will be allowed - up to two hours of follow-up DSMT annually,- the ADA states.

Tip: Medicare may still cover diabetes education and nutrition counseling even when the patient has exceeded the above frequency allowances. -When the patient has a change in status, such as insulin, and the MD orders MNT services beyond the original benefit inclusions, you should report G0270-G0271,- Latanick says.
  
Step 4: Check Diagnostic Requirements

To ensure diabetes education coverage, you must include a covered ICD-9 diagnosis. -The patient must be a diabetic,- Latanick says.

Action: Assign the appropriate five-digit number from 250.00-250.93. Medicare considers nutrition counseling appropriate for any diabetes mellitus diagnosis in the 250.xx series, as well as gestational diabetes (648.0x, Other current conditions in the mother classifiable elsewhere, but complicating pregnancy, childbirth, or the puerperium; diabetes mellitus), according to the Medicare Part B Reference Manual, Chapter 13, Section 13.8. DSMT is covered for -Medicare beneficiaries at risk for complication from diabetes or recently diagnosed with diabetes,- CMS states.

For more information on coding MNT and DSMT, view the ADA's FAQs at www.diabetes.org/for-health-professionals-and-scientists/recognition/dsmt-mntfaqs.jsp#Q5.