Weight management counseling: a guide to
understanding coverage, reimbursement and
opportunities for registered dietitians
Pam Michael,
MBA, RD
Suzanne Brodney
Folse, PhD, RD
Learning objectives
Weight Management Newsletter
After reading this article the reader will
be able to:
1. D
escribe the medical nutrition
therapy (MNT) current procedural
terminology (CPT) codes and identify
when each should be used.
2. D
escribe the process to become a credentialed provider with a health-care
provider.
3. L
ist five resources to assist with MNT
reimbursement that can be found on
the American Dietetic Association
(ADA) Web site (www.eatright.org).
I
s weight management counseling reimbursed? What seems like a
straightforward question that registered dietitians (RDs) should be able to
answer is actually a complex process that
is constantly evolving. Services reimbursed for weight management counseling and reimbursement rates differ
within and among states and insurance
companies. Uncovering what is reimbursable in your area takes some dedicated time and a bit of detective work.
Americans are nearly twice as likely as
Europeans to be obese (33.1% vs. 17.1%,
respectively) according to an article published in a recent Health Affairs Journal
(1). While the obesity epidemic in the
United States is well publicized, coverage
and reimbursement for MNT services,
essential for improving weight and
overall health, are less apparent and vary
considerably across the country. While
government groups such as the Institute
of Medicine and the U.S. Preventive
Services Task Force recognize the importance of nutrition, other organizations
question the current health-care system.
A recent report from the President’s
Cancer Panel noted, “The links between
cancer, diet, and obesity have not been
accepted sufficiently by the health insurance industry to motivate widespread
coverage for health-promoting/cancer
prevention services such as nutrition
counseling or obesity related treatment
services” (2).
Current coverage for weight
management services
Gathering data on coverage policies
and overall reimbursement for RDs is a
challenge in itself. Results from a coding
survey conducted by the ADA Coding
and Coverage Committee indicated approximately 18% of RD survey responders (n=1,589) receive reimbursement
for obesity/overweight. While the survey
indicated reimbursement was occurring, the study was not able to determine
which payer groups have defined coverage for nutrition services for obesity/overweight. Further, it was unclear
whether the RDs under contract were
reimbursed through billing the payer
group directly or through other means
such as incident to a physician’s services
(see sidebar on page 5).
Fitzner et al. reported results of an
ADA environmental scan of selected
health plans to assess the plans’ coverage
policies, perceptions and expectations of
dietetics services (5). The study’s findings
suggest that between 1999 and 2002,
there was a shift toward more uniform
coverage and less geographic variety in
nutrition coverage among the 23 health
plans included in the study. While these
4
findings were not intended to represent
all managed care organizations or the
health care marketplace, they affirm and
support the importance of practitioners’ efforts to increase MNT coverage
through interactions with health plans or
self-insured employer groups.
In another study, Baronowski and
King noted variability in coverage of
services, such as MNT provided by RDs,
in part based on insurance industry
mergers and lack of set reimbursement
policies, which adversely affect the ability
to obtain insurance coverage for health
services (6). The authors noted that
groups and individuals in the nutrition
profession need to continue their efforts
to inquire about reimbursement practices and assist insurance companies in
developing policies.
Legislation
In addition to supporting new and existing payer policies for nutrition services
such as MNT, enacting legislation is a vehicle to expand coverage decisions. ADA
accomplished MNT coverage legislation
in December 2000 when Congress passed
a Medicare Part B MNT provision as part
of the Benefits Improvement and Protection Act (7). The Medicare Part B MNT
bewnefit is limited to MNT provided by
licensed (as applicable) RDs for qualifying individuals with diabetes and nondialysis kidney disease. Due to budget
restrictions, other diseases and conditions were pulled out of the Medicare
MNT legislation. The legislative effort for
federal MNT coverage was a huge task,
however, involving a 40-year effort by
ADA and its members. New legislation
to expand Medicare MNT to other diseases has been limited due to competing
priority issues that government officials
are debating in Congress.
States also face challenges and barriers
in expanding coverage for nutrition ser-
vices through legislative activity. Because
of the lengthy process and costs of enacting legislation, plus lack of control where
policy details may be determined by
groups besides the payer, some insurance
plans have collaborated to create voluntary coverage policies. This was the case
in Rhode Island several years ago when a
major payer averted legislative activity by
voluntarily drafting coverage for nutrition counseling provided by RDs. The
coverage was fairly comprehensive, but
even in this case, individual MNT treatment was not available for obesity.
The September 2006 issue of the
Journal of the American Dietetic
Association (Public Policy News section)
provides a timely article on the current legislative situation and barriers to
an effective obesity bill (7). This article
sheds additional light on reimbursement
for nutrition services for treatment of
overweight and obese individuals.
Employer demands
n An integral, although incidental, part of the physician’s professional service
n Commonly rendered without charge or included in the physician’s bill, and for
which payment is not made under a separate benefit category listed in §1861 (s)
of the Balanced Budget Act
n Of a type that are commonly furnished in physician’s offices or clinics
n Furnished by the physician or by auxiliary personnel under the physician’s
supervision (4)
If an RD does not have contracts with private insurance plans, but is employed by
a physician where the physician could bill private insurance companies for nutrition
services, the physician should be encouraged to review his/her contracts with the
insurance plan(s).*
* According to an American Medical News article posted on the American Medical
Association’s Web page, physicians should, with respect to commercial insurer
regulations, keep in mind that each commercial insurer has its own policy for billing
for non-physician practitioners’ services. Some require the non-physician practitioner’s services to be billed using the non-physician provider’s number, while other
commercial insurers require the non-physician practitioner services to be billed under the physician’s provider number. If a physician is unsure how to bill, he or she
should call the insurer’s director of provider relations. Physicians should also make
sure they are aware of state laws regarding billing for other non-physician practitioners. Some of these payment mechanisms hinge on current state regulations.
the conditions authorized to be treated
by MNT (12).
Payer policies for RD weight
management services
Identifying national and local payer
policies for nutrition services is a first
step in determining coverage and reimbursement opportunities for RDs. Some
payers, such as Aetna, have developed a
Clinical Policy Bulletin for nutritional
counseling provided by RDs; however, the policy includes the following
disclaimer, “Clinical Policy Bulletins are
developed by Aetna to assist in administering plan benefits and constitute
neither offers of coverage nor medical
advice. This Clinical Policy Bulletin contains only a partial, general description
of plan or program benefits and does not
constitute a contract.”
As a way of identifying state-specific
coverage details for nutrition services
such as MNT, ADA relies on feedback
from members and affiliate reimbursement representatives (ADA members appointed by their state dietetic association
5
or dietetic practice group who serve as
resources for local coverage information
as well as coding and Medicare MNTrelated resources). RDs have reported
significant differences in local MNT
coverage—even among various regions
of the state. In addition, health-care
benefits and coverage may differ among
the payer’s product lines, such as health
maintenance organizations (HMO),
point of service (POS), and preferred
provider organization (PPO) products.
Some of the new MNT policies for
obesity have been created within certain
payer’s products as a distinct disease
management program. Thus, contacting
the payer’s regional provider relations
office is critical in determining coverage
policies and eligibility for RD provider
participation on the plan.
Last year, the ADA Nutrition Services
Coverage Team conducted a survey
among the reimbursement representatives and found that several plans,
primarily on the East Coast, cover RD
See Reimbursement, page 6
Volume 5, Number 3, Winter 2007-2008
As the prevalence of overweight and
obesity increases in the U.S. population,
it is also increasing in the workforce. A
recent analysis indicated that a person
who is obese incurs on average $2,152
per year more in health-care costs and
$863 per year in lower productivity and
absenteeism costs, when compared with
a person of normal weight (9–10). Jans
et al. reported that obese employees were
absent 14 a year days more than normal weight employees (11). Given the
direct and indirect costs associated with
overweight and obesity, many employers
are offering programs to help employees
address excess weight.
Employers can add or delete specific
benefits, such as coverage for nutrition services provided by RDs, as they
determine the health benefit provisions
for their employees. Texas Instruments
is one example of a Fortune 100 company that realized the cost-effectiveness
of MNT provided by RDs, and it now
includes MNT in the company’s health
benefits. The benefit allows four visits
with an RD for each disease/condition
that afflicts the company’s employees;
obesity and morbid obesity are two of
“Incident to” services under Medicare Part B
are defined by the Centers for Medicare
& Medicaid Services as services that are:
Reimbursement, page 5
provided services for obesity/overweight/
abnormal weight gain. A chart of the results is accessible to ADA members from
ADA’s Web page in the “Private Insurance MNT” section at www.eatright.org/
mnt. Below are a few payers that have
indicated RD coverage for weight conditions (check payer policies for details
and/or coverage changes):
n Anthem (Blue Cross and Blue Shield of
Weight Management Newsletter
New Hampshire) for “overweight” and
“abnormal weight gain”
n Harvard Pilgrim Healthcare (in New
Hampshire) for “morbid obesity”
n Care First BlueCross BlueShield (in
Virginia) for “obesity”
n Aetna (in Virginia) for “obesity” and
“overweight”
n Cigna Health Plan and Vytra Health
Plans (in New York) for “abnormal
weight gain”
n Blue Cross and Blue Shield of Northeastern Pennsylvania: part of the plan’s
disease management weight management program for adults and children
(> 2 years old)
n Blue Cross and Blue Shield of North
Carolina (BCBSNC): weight management as part of the plan’s disease management weight management program
RDs have played an active role in creating or helping to define coverage policies for weight management for several of
the plans listed above. For example, entrepreneurial RDs from the North Carolina
Dietetic Association, along with the North
Carolina Weight Management Initiative,
spearheaded a local effort that led to new
coverage for weight management nutrition services in their state. This project
has evolved into an ADA-sponsored
three-year research initiative to evaluate
BCBSNC’s new coverage of MNT and
lifestyle case management by RDs.
Effective Jan. 15, 2007, Blue Cross of
Northeastern Pennsylvania (BCNEPA)
offers a weight management program
for many of its members as part of a new
comprehensive Blue Health Solutions
offering. To qualify for the program,
members must meet one or more of the
following criteria:
Table 1. MNT current
procedural
terminology codes*
n 9
7802: MNT, initial assessment and
intervention, individual, face-to-face,
each 15 minutes
n 9
7803: MNT, reassessment and
intervention, individual, face-to-face,
each 15 minutes
n 97804: MNT, group, 2 or more
individuals, each 30 minutes
CPT codes, descriptions and material only are
copyright ©2000 American Medical Association.
All Rights Reserved.
CPT 2006 Current Procedural Terminology.
Table 2. Health care
common procedure
coding system codes*
n S
9470: Nutritional counseling
dietitian visit
n S
9465: Diabetic management
program dietitian visit
n S
9452: Nutrition classes nonphysician provider, per session
n S
9449: Weight management classes
non-physician provider, per session
*To avoid claims processing problems, RDs should call the payer’s provider relations and check payer
policies for information on codes (MNT CPT or S HCPCS) to use on claims for obesity services.
n Adults: (1) body mass index (BMI)
equal to or greater than 30, or (2) Waist
circumference of over 40 inches for a
male or over 36 inches for a female
nC
hildren: BMI-for-age percentile equal
to or greater than the 85th
Participants will receive a nutrition
toolkit to kick off their weight management efforts, be placed on a mailing list
for a periodic weight management newsletter, and receive telephonic coaching/
monitoring by the Blue Cross RD. The
RD providers will coordinate care with
the member’s physician, as well as collect
and report outcome data back to BCNEPA. An incentive program is planned
to reward members for achieving weight
management goals.
As of January 2008, the benefit will
consist of MNT with a licensed RD for a
maximum of six visits with a $10 co-payment per contract year and will be available for all disease conditions including
obesity. Additional MNT beyond the
six visits is currently being designed for
those who enroll in the weight management program. Tentative plans of a total
of 12 additional visits is being proposed
based on member progress through a
benefit adaptation route. The development of this program is led by Susanne
Luchetti, MS, RD, LDN.
6
In addition to coverage details reported by RDs, in the 2005 Health Plans
Emerging As Pragmatic Partners in Fight
Against Obesity report, the National Institute for Health Care Management invited
seven prominent health-care leaders to
discuss their viewpoints and insights on
obesity and highlight what needs to be
done to initiate effective, comprehensive
programs for prevention and treatment.
As described in the report (accessed from
ADA’s Web page at www.eatright.org/
mnt, “Private Insurance MNT”, “Coverage”), there are a variety of obesity prevention programs and partnerships that
can serve as models for other health plans
looking to combat obesity. While the
following groups have adopted certain
programs for obesity, RDs must check
payer policies to see if the programs
apply to their geographic area.
n Aetna
n Affinity Health Plan
n Blue Cross and Blue Shield of
Massachusetts
n Blue Cross and Blue Shield of North
Carolina
n Empire Blue Cross and Blue Shield
n HealthPartners
n Highmark, Inc.
n Horizon Blue Cross Blue Shield
Table 3. Education and training for patient self-management CPT codes
The following codes are used to report educational and training services prescribed by a physician and provided by a qualified,
nonphysician health-care professional using a standardized curriculum to an individual or a group of patients for the treatment of
established illness(s)/disease(s) or to delay comorbidity(s). Education and training for patient self-management may be reported
with these codes only when using a standardized curriculum as described below. This curriculum may be modified as necessary
for the clinical needs, cultural norms and health literacy of the individual patient(s).
n 98960:
Education and training for patient self-management by a qualified, non-physician health care professional using a
standardized curriculum, face-to-face with the patient (could include caregiver/family), each 30 minutes; individual patient.
n9
8961: Education and training for patient self-management by a qualified, non-physician health care professional using a
standardized curriculum, face-to-face with the patient (could include caregiver/family), each 30 minutes; 2-4 patients
n9
8962: Education and training for patient self-management by a qualified, non-physician health-care professional using a
standardized curriculum, face-to-face with the patient (could include caregiver/family), each 30 minutes; 5-8 patients
The purpose of the educational and training services is to teach the patient (may include caregiver(s)) how to effectively selfmanage the patient’s illness(s)/disease(s) or delay disease comorbidity(s) in conjunction with patient’s professional health-care
team. Education and training related to subsequent reinforcement or due to changes in the patient’s condition or treatment plan
are reported in the same manner as the original education and training. The type of education and training provided for the patient’s clinical condition will be identified by the appropriate diagnosis code(s) reported.
The qualifications of the nonphysician healthcare professionals and the content of the educational and training program must be
consistent with guidelines or standards established or recognized by a physician society, nonphysician health-care professional
society/association, or other appropriate source.
For more information on the correct use of the education and training codes, refer to the 2008 CPT code book, which can be
purchased at https://catalog.ama-assn.org/Catalog.
CPT copyright ©2005 American Medical Association.
n Kaiser Permanente
n Premera Blue Cross
n WellPoint Health Networks
In 2000, ADA submitted an MNT code
proposal to the American Medical Association (AMA) CPT committee, the
national association that maintains the
CPT coding system. The codes were
accepted and available for use by RDs in
2001. While some payers have been slow
to recognize the CPT codes as ones that
best define the MNT services provided
by RDs, RDs report that the codes are
more universally accepted today.
The MNT CPT codes describe the
procedure or service provided by RDs,
with the code nomenclature defining the
code as an MNT nutrition assessment
and intervention. MNT codes exist for
initial and follow-up visits with the RD,
as well as for individual or group encoun-
7
Additional procedure codes that may
apply for prevention services
To expand RD billing opportunities
for preventive nutrition services, ADA
participated in the development of new
education and training CPT codes (Table
3). These services must be prescribed by
a physician, and involve use of a standardized curriculum to teach the patient
(and caregiver(s)) how to effectively selfmanage the patient’s illness(s)/disease(s)
or delay disease comorbidity(s). The preventive aspect of the new education and
training codes are what distinguish the
services from MNT services for chronic
conditions. Preventive type nutrition
classes (where the education and training
codes could possibly be used by RDs to
prevent or delay comorbidities) include
topics such as low-fat cooking, restaurant
dining tips and healthy grocery store
shopping information.
The education and training codes were
See Reimbursement, page 27
Volume 5, Number 3, Winter 2007-2008
CPT and HCPCS codes
applicable for obesity and
other diseases
ters (see Table 1). The MNT codes can be
used with any diagnosis, including obesity diagnosis codes (see Table 4). However,
while the MNT procedure codes allow
RDs a mechanism to report the service/
procedure they provide for obesity and
overweight on claims, the MNT code in
itself does not verify a payer’s coverage or
reimbursement for the MNT service. RDs
need to check payer policies to determine if MNT coverage is available, and
specifically, whether MNT is covered and
reimbursable for obesity/overweight.
Prior to the MNT CPT codes, BlueCross BlueShield and other payer groups
created codes for services where no CPT
code existed. Known as the HCPCS
(“hick-picks”) codes, or the Healthcare
Common Procedure Coding System, several were created to describe nutrition,
dietitian, or non-physician services for
nutrition classes or nutrition counseling
(Table 2). Based on payer policies, some
payers still use these codes along with or
instead of the MNT procedure codes.
Reimbursement, from page 7
added to the CPT code system last year,
yet it is unclear the extent to which payers
are accepting and paying for services billed
under these new codes. Since Medicare
Part B only covers MNT services provided
by RDs for diabetes and non-dialysis
kidney disease, these new codes are not
reimbursable under the federal health
program. Depending on payer policies,
non-Medicare payers may allow RDs to
use the codes for classes that may be used
in conjunction with a weight management
program or for prevention of obesity.
Practitioners can check the payer policies
and/or fee schedules to see if the education and training codes are in use and
whether they are allowed for use by RDs
for preventive type nutrition services.
Diagnosis codes for obesity
and overweight
n 278.0: Overweight and obesity
se additional code (V85.0-V85.54) to identify Body Mass Index (BMI), if known
U
Excludes: adiposogenital dystrophy (253.8) and obesity of endocrine origin NOS
(259.9)
• 278.00: Obesity, unspecified as defined by BMI between 30.0 and 38.9
•2
78.01: Morbid obesity or severe obesity as defined by increased weight beyond
limits of skeletal and physical requirements (125 percent or more over ideal body
weight), as a result of excess fat in subcutaneous connective tissues or BMI
greater than 39
• 278.02: Overweight as defined by BMI between 25 and 29.9
n 278.2: Localized adiposity; fat pad
Source: AMA International Classification of Diseases ICD-9-CM 2008; Physician Volumes 1 and 2;
9th Revision-Clinical Modification
denied. The ICD-9 codes for obesity and
overweight are presented in Table 4.
Becoming a credentialed
provider with a payer
Contact the reimbursement representative within your state dietetic association
to inquire about local payers that cover
MNT and nutrition services provided by
RDs. RDs should also call the provider
relations department for local payers to
determine coverage and payment for
RD MNT/nutrition services. If coverage is available, RDs will need to inquire
whether the payer will accept additional
RD providers in their payer networks. If
enrollment is open to RDs, the RD will
first need to become a provider with the
insurance company and obtain a copy
of the payer’s policies and procedures
including the fee schedule for RDs and
codes to use on claims. This information
varies by insurance company. Each insurance company will have a medical policy
for nutrition counseling. As the provider,
the RD is required to obtain this information and review these policies on, at
least, an annual basis.
How are reimbursement rates decided?
Payers may use a variety of sources for
determining the fee schedule for RDprovided nutrition services such as MNT.
Some payers have indicated they pay
RDs based on a certain percent above the
27
Medicare Part B physician fee schedule
for outpatient Medicare services. Others
internally determine their fee schedule
rates, which in some cases involves market research to determine “the going rate”
for nutrition services in the community.
These independent surveys, which reflect
the RDs’ or facilities’ usual and customary fees, serve as the basis for setting the
payer’s fee schedule.
Just as the procedure for setting the
payer’s fee schedule differs among the
various plans, the frequency with which
they update the schedules also varies.
Some payers annually adjust their fee
schedule while others make updates
every few years. Even though the payer
sets the rate and updates, RDs may have
the opportunity to share information
and negotiate fee changes among certain
payers. It is important that RDs periodically review the payer’s fee schedule to
determine changes and consider whether
to maintain a contract with the plan.
Additional resources Recognizing ADA members’ interests in
codes, coverage and reimbursement for
nutrition services, ADA has developed a
variety of resources to help advance RDs’
business practice skills, improve members’ compliance with payer regulations
and provide tools for expanding local
See Reimbursement, page 28
Volume 5, Number 3, Winter 2007-2008
Diagnosis codes describe an individual’s
medical condition that is determined
by the treating physician. In addition
to procedure codes, diagnosis codes
are required on claims submitted to
government and private payer groups
for payment of health services. ICD-9
coding or the International Classification
of Diseases, Ninth Revision, is the official
coding system used for tracking disease/
condition incidence in all healthcare settings in the United States.
The government and private insurance plans recognize doctors of medicine and osteopathy as the legal entities trained and licensed to perform a
medical diagnosis. Both physicians and
certified coders, specifically trained in
proper code selection, are responsible for
determining the corresponding diagnosis
code for the diagnosed condition/disease.
Certified coders are granted the authority to evaluate the physician’s diagnosis
documentation and select and confirm
codes to correspond with medical diagnosis for claims processing activities.
Confirming a patient’s diagnosis and
ICD-9 code(s) with the physician is an
important step for completing a claim
for MNT services provided by RDs. If
the wrong code or an incomplete code is
listed on the claim, the payment may be
Table 4. Diagnosis codes for obesity
and overweight
Reimbursement, from page 27
coverage for nutrition services. Unless
otherwise noted, all resources listed
below are posted in the MNT
section on ADA’s Web page (www.eatright.org/mnt).
Weight Management Newsletter
n Third-party payer brochure. Does
your local insurance payer know an
investment in the services of an RD today can save him or her money tomorrow? Use this new brochure, produced
by ADA and Commission on Dietetic
Registration (CDR), to increase coverage of RD-provided nutrition services.
n MNT Works Kit. A marketing tool
designed to increase MNT coverage
and consumer access to MNT services
provided by RDs. Use the MNT Works
Kit during meetings and presentations
to local third-party payers, employer
groups, and hospital finance and
billing departments to expand MNT
coverage. The kit includes MNT return
on investment, description of MNT
evidence-based nutrition practice
guidelines, stakeholders’ comments on
the importance and effectiveness of
nutrition services, and more.
n ADA Guide to Private Practice: An Introduction to Starting Your Own Business by Ann S. Litt, MS, RD, and Faye
Berger Mitchell, RD. This introductory
guide is the ideal resource for any dietetics professional considering private
practice. By incorporating checklists,
self-assessments, sample forms and
real-life examples from successful practitioners, the authors provide an honest
look at the challenges and rewards of
going out on your own. Topics include:
the pros and cons of private practice;
choosing a business structure, advisors for your practice, and office space;
marketing; networking; and accepting
payment, including reimbursement
considerations for your services.
n Join the ADA Reimbursement
Community of Interest (CoI) at
www.eatright.org/mnt. The reimbursement CoI is available to ADA
members who desire to learn more
about coverage for MNT and exchange
best practices to help advance coverage
of nutrition services with health plans,
employers and third party payers.
Through the CoI format, members
have an interactive online tool that
offers improved communications and
features that traditional listservs cannot
provide, including a private and secure
area for members to connect, plus archived announcements and messages.
n ADA state dietetic association and dietetic practice group reimbursement
representatives. These representatives
are available to assist with local coverage and coding issues and help RDs
connect with other RD providers to
share best practices. Representatives are
listed in ADA’s leadership directory, accessible from www.eatright.org under
the “Governance” tab.
n The Weight Management and other
ADA dietetic practice groups (DPGs)
have resources to aid members with
reimbursement issues.
•M
embers of the Weight Management DPG can post questions related
to reimbursement on the electronic
mailing list. Discussions around and
answers to these questions will be
posted on the Weight Management
DPG Web site.
•M
embers of the Nutrition Entrepreneurs DPG can use the practice
group’s mentoring service where a
seasoned practitioner provides advice
to RDs new to the private practice
arena. Business practice articles on
the Web page and in newsletters are
also available. You can access information on this practice group from
its Web page at www.nedpg.org/.
n ADA staff from the Nutrition Services
Coverage Team are another resource
for code, coverage and compliance
information. Contact ADA staff at
reimburse@eatright.org.
n ADA Evidence-Based Nutrition
Practice Guidelines/Nutrition Care
Process. ADA provides members with
practice tools and resources to provide quality, safe and effective MNT
services for a variety of conditions and
diseases including weight management.
RDs can use the ADA Evidence-Based
28
Nutrition Practice Guidelines to apply
cutting-edge, synthetic research to
practice. For additional information go
to the ADA Evidence Analysis Library
at www.adaevidencelibrary.com/default.cfm?library=EAL.
Strategy/position of the ADA
on reimbursement of weight
management counseling
ADA coding and coverage activities are
aligned with ADA’s strategic directives
and priority areas of work. ADA committees and teams, including the Coding
and Coverage Committee, the Nutrition
Services Coverage Team, and others
undertake activities to:
n Increase demand for and utilization of
services provided by members
n Empower members to compete suc-
cessfully in a rapidly changing environment
ADA has also identified obesity/overweight (prevention and intervention to
attain and maintain healthy weights, with
a focus on children) as one of several
priority areas within the Association.
Raising the profile of the RD and
creating tools that RDs can show private
insurance companies, medical directors,
billing departments and other payers the
quality of the services they provide are
key activities that support these initiatives. Plans for a targeted communication to payers is underway to increase
recognition of the RD and recognition
of the quality, evidence-based services
RDs provide. ADA’s Coding and Coverage Committee, through its coding work
with the American Medical Association
(AMA), increases recognition of RDs
among medical groups while pursuing
codes for RD use among private payers.
Additionally, ADA continually works
to strengthen ties with state dietetic associations and dietetic practice groups to
empower local members to advocate for
expanding coverage and reimbursement
for nutrition services provided by RDs.
ADA’s involvement with these groups includes collaborating with reimbursement
representatives to share information and
disseminate materials to RDs who are
working to expand coverage of nutrition
services, including weight management
counseling.
When it comes to expanding coverage for nutrition services such as weight
management counseling, ADA helps
members effectively communicate with
payers. Members and/or their state
dietetic association and DPGs can work
together to approach payers and influence coverage decisions at their source—
the local level. RDs can get involved by
adopting the seven MNT advocacy tips
listed in Table 5.
Case studies
What is involved in determining coverage and payment for weight management
services provided by RDs? The following
case studies describe the steps to take
before initiating MNT services.
MNT works in many ways to enhance patient care, with the bonus of saving lives as
it saves money. How can you help your patients receive MNT as a benefit? Apply
these seven steps to lay the groundwork for a more successful future by advocating
for local coverage or expansion of MNT services.
1. Assess local coverage provided by insurers. If one industry leader is covering
nutrition services for RDs in private practice and outpatient settings, is this possibly
a model to emulate among other plans?
2. Know your patients’ nutrition needs and state that in your goals to policy decision
makers.
3. Get information on local insurance companies, including their annual reports
and past interactions with RDs (e.g., amount spent on medications, where the plan
is targeting care for certain high-risk/high-cost diseases/conditions). Gather state
data on disease incidence, state health initiatives, nutrition outcomes studies and
successful related campaigns. Check local department of public health Web pages
for data on disease incidence. Use these and outcomes data from local hospitals or
private practitioners’ practices to show the impact of nutrition services.
4. Seek out events or special initiatives that might support your effort. Review any
pending legislation that might aid in your efforts. Consider special task forces convened by state legislative leaders (e.g., governor, obesity initiative task force).
5. Talk to ADA members from around the country to learn from their experiences.
Get information and advice. Additionally, identify external advocates for your cause.
This might be legislators, medical directors affiliated with the plan, other health care
professionals or consumers. Consider asking these individuals for letters of support
to help advocate for your cause.
6. Identify your advocacy team.
7. Arrange to meet with the payer’s medical director and other decision makers.
Follow up with a written confirmation and brief overview of your interest in nutrition
coverage. Determine your best advocates to present key points at the meeting.
Use ADA’s MNT Works Kit and collect local data, testimonials and other materials
that tell the MNT story effectively. At the meeting, arrive on time, and keep to your
agenda. Strive to build relationships with your goals in mind. Arrange a follow-up
meeting and send a thank-you note and summary of next steps.
services, some RDs ask the patient to
gather this information and then call the
RD back to share the information and
schedule an appointment.
Another item to determine prior to
providing the first MNT appointment is
whether the RD is able to receive direct
reimbursement from the plan, or whether the patient would pay out-of-pocket
and submit the claim to the payer independently for repayment to the patient.
In order to receive direct reimbursement
from the payer, RDs frequently need
29
to enter into a contract with the payer,
which involves submitting documentation to verify registration and licensure,
as applicable. Even though an RD may be
under contract with a particular payer,
it is still important to verify the patient’s
coverage since employers covered by the
same payer group may have different
benefit provisions, which may or may
not include MNT. Clearly describing the
RD, or clinic payment policies, including
See Reimbursement, page 30
Volume 5, Number 3, Winter 2007-2008
Case study 1
Mr. Jones calls the RD to schedule an
appointment for weight loss. What
steps should the RD consider to verify
coverage and future payment for MNT
services?
The RD, or staff who schedules outpatient service appointments within the
facility, should gather specific information from the patient or caregiver prior
to scheduling the RD appointment. For
example, interview Mr. Jones to determine if he has insurance and whether the
insurance covers RD nutrition services
such as MNT for obesity/overweight.
Determine whether he needs a physician referral as required by the facility or
insurance plan. If no coverage is available
for nutrition services, some plans may
cover the service on a case-by-case basis
with documentation of medical necessity
provided from the physician. If Mr. Jones
is uncertain about his coverage, he needs
to call the customer service number on
the back of his insurance card or the RD
can contact the insurance company for
him. It is important to inquire specifics
such as co-payments, deductible, and
number of visits allowed or maximum
dollar allowed for the benefit. Because
verifying insurance coverage may take
time, reducing the billable hours an RD
can spend with patients to provide MNT
Table 5. MNT coverage advocacy work: seven
steps to make a difference in your career
and your clients’ lives
Reimbursement, from page 29
Weight Management Newsletter
collection of the co-payment and/or deductible and charges for missed appointments are important business functions
to take care of before the MNT service
even begins.
Once the coverage and payment procedures are determined for the patient, it
is also important to review materials the
patient should bring to the first visit, such
as food records, completion of a previously mailed nutrition assessment form
and list of medications. Additionally, the
RD should set patient expectations and
describe what is invowlved, including the
estimated number of visits that will generally be needed to provide MNT services
based on the patient’s condition/disease.
As information is gathered from the
patient, RDs and/or the facility must also
consider and adhere to privacy (Health
Insurance Portability and Accountability
Act [HIPAA]) regulations to make sure
the patient’s protected health information, such as the patient’s name, address,
insurance plan and plan group number,
is kept private and not accessible to individuals not involved in the patient’s care.
Case study 2
Mrs. Smith, a 70-year-old individual with
Medicare Part B health coverage, talks
with her doctor about referral to an RD
for weight loss to help alleviate her hip
and knee pain. What steps should the RD
consider to verify coverage and future
payment for MNT services?
Medicare Part B currently covers
MNT provided by enrolled, licensed (if
applicable) RDs for diabetes and nondialysis kidney disease. If the patient’s
diseases and conditions are obesity and
knee pain, Medicare will not cover or
reimburse the RD for MNT services. In
this case, the disease is not covered by
Medicare, so the RD should determine if
Mrs. Smith has coverage through another
payer that might pick up payment for
non-Medicare covered services. If no
other insurance coverage is available,
Mrs. Smith would need to pay out-ofpocket for the MNT services provided for
weight loss.
Note: MNT services for other diseases/
conditions besides diabetes and renal
diseases cannot be billed as “incident to”
physician services under the Medicare
Part B program since the government
reimburses “incident to” services only to
the extent the services would otherwise
be covered by Medicare. See side bar on
page 5 for more information on “incident
to” services.
Pam Michael, MBA, RD, is director of
the American Dietetic Association (ADA)
Nutrition Services Coverage Team, where
she strategically plans and directs medical
nutrition therapy marketing activities to
niche groups including Medicare, managed
care organizations, private insurers and
employer groups. Over her sixteen-year
tenure at ADA, Pam previously directed
the Association’s affiliate relations, diversity, and student recruitment and retention
activities, and coordinated ADA’s membership marketing efforts.
Suzanne Brodney Folse, PhD, RD, is
manager of research and outcomes for The
Health and Wellness Institute (Providence,
RI) where she manages funded research
projects, leads grant development, and
is responsible for the design and implementation of all measurement tools for
evaluating the effectiveness of the health
management solutions offered through
the Institute. Dr. Brodney Folse currently
serves as the reimbursement representative
for the WM DPG.
References
1. Anderson GF, Frogner BK, Reinhardt UE.
Health spending in OECD countries in 2004:
an update. Health Affairs. 2007;26:1,481-1,489.
2. The President’s Cancer Panel, 2006-2007
Annual Report. Promoting Healthy Lifestyles:
Policy, Program, and Personal Recommendations for Reducing Cancer Risk. Bethesda, MD:
U.S. Department of Health and Human Services and The National Institutes of Health,
National Cancer Institute; 2007.
3. White JV, Ayoob K, Gregoire M, et al.
Registered dietitians’ coding practices and
patterns of code use. Submitted to: J Am Diet
Assoc. October 2007.
4. Medicare Carrier’s Manual. Baltimore, MD:
Centers for Medicare and Medicaid Services.
Available at http://www.cms.hhs.gov/Manuals/01_Overview.asp. Accessed November 2007.
5. Fitzner K, Myers EF, Caputo N, et al.
Are health plans changing their views on
nutrition service coverage? J Am Diet Assoc.
2003;103:157-161.
6. Baranoski CL, King SL. Insurance companies are reimbursing for MNT. J Am Diet
Assoc. 2000;100:1,530-1,535.
7. Smith RE, Patrick S, Michael P, et al.
Medical nutrition therapy: the core of ADA’s
advocacy efforts (part 1). J Am Diet Assoc.
2005;105:825-834.
8. Smith R. Passing an effective obesity bill. J
Am Diet Assoc. 2006;106:1,349-1,353.
9. Burton WN, Chen CY, Conti DJ, et al.
The association of health risks with on the
job productivity. J Occup Environ Med.
2005;47:769-777.
10. Anderson L, Martinson B, Crain AL, et al.
Health care charges associated with physical inactivity, overweight, and obesity. Prev
Chronic Disease. 2005;2:1-12.
11. Jans M, van den Heuvel SG, Hildebrandt
VH, et al. Overweight and obesity as predictors of absenteeism in the working population of the Netherlands. J Occup Environ Med.
2007;49:975-980.
12. Israel D, McCabe M. Using diseasestate management as the key to promoting
employer sponsorship of medical nutrition
therapy. J Am Diet Assoc. 1999;99:583-588.
The New Adult Weight Management Toolkit
… helps you incorporate evidence-based care for
adults who are overweight and obese. The toolkit, developed by ADA members Christina Biesemeier, MS,
RD, LD, FADA, and Ruth Ann Carpenter, MS, RD, LD,
offers teaching tools, progress note forms, case studies, a sample referral form, client education materials
30
and outcomes management tools. It incorporates the
Nutrition Care Process and Standardized Language
and is a companion to the Adult Weight Management
Evidence-Based Nutrition Practice Guideline in the
Evidence Analysis Library. The toolkit is available at
www.adaevidencelibrary.com/store.cfm.
CPE Credit
Instructions
3) Mail or e-mail the following information to Paula Peirce,
PhD, RD, to receive your certificate of completion: article
title, request for CPE credit, name, address, telephone number, e-mail address and American Dietetic Association (ADA)
member registration number.
The Commission on Dietetic Registration (CDR) has approved the article, “Weight management counseling: a guide
to understanding coverage, reimbursement and opportunities
for registered dietitians” for one hour of continuing professional education (CPE) credit. CPE eligibility is based on
active Weight Management (WM) Dietetic Practice Group
(DPG) membership status from June 1, 2007 to May 31, 2008.
Paula Peirce, PhD, RD
14901 E. Hampden Ave., Suite 110
Aurora, CO 80014
ppeirce@aol.com
Instructions to receive credit:
4) Once this information has been received, Paula will e-mail
your certificate of completion for the CPE credit. Retain the
certificate for your records in case CDR audits you.
1) Read the article, “Weight management counseling: a guide
to understanding coverage, reimbursement and opportunities
for registered dietitians”.
5) WM members receive credits by contacting Paula Peirce
within one year of the publication of this issue of Weight
Management Newsletter. Member participants may obtain
CPE credit until Jan 31, 2009.
2) Answer the following single-answer, multiple-choice questions. For each question, select one best response. Compare
your answers to the answer key on page 31.
CPE credit self-assessment questionnaire
B. lack of set reimbursement policies
C. state specific coverage policies
D. all of the above
“Weight management counseling: a guide to understanding
coverage, reimbursement and opportunities for registered
dietitians”
4. To become a credentialed provider with a payer, RDs need
to:
A. complete the ADA reimbursement certification course to
receive appropriate credentials
B. provide services and direct patients/ clients to contact their
insurance provider directly
C. contact the provider relations department for local payers
to determine coverage for MNT
D. provide documented evidence of benefit for MNT for the
specific diagnoses to be treated
Weight Management Newsletter
Answer the following questions. Follow the directions above
to obtain CPE credit for reading this article.
1. The CPT (Current Procedural Terminology) coding system is maintained by:
A. the National Institutes of Health
B. the U.S. Preventative Services Task Force
C. the American Medical Association
D. the Institutes of Medicine
5. Passed by Congress in 2000 as part of the MNT Improvement and Protection Act, the Medicare Part B MNT benefit is
limited to MNT provided by licensed RDs:
A. for qualifying individuals with diabetes and non-dialysis
kidney disease
B. for obesity/overweight in a limited number of states
C. for obesity/overweight with the presence of one or more
co-morbidities
D. to individuals referred by their PCP with a nutrition
related CPT code
2. A recent coding survey conducted by the ADA Coding
and Coverage Committee:
A. identified which payer groups have defined coverage for
nutrition services for obesity/overweight nationwide
B. found that 48% of RDs were receiving reimbursement for
obesity/overweight
C. was not able to determine whether reimbursement was
achieved by direct billing the payee group or through other
means
D. found that reimbursement for nutrition services for obesity/overweight was most likely in the western U.S.
6. All of the following are true regarding use of MNT CPT
codes EXCEPT:
A. describe the procedure or service provided by RDs
B. can be used for individual or group encounters
C. can be used with any diagnosis, including obesity diagnosis
3. Variability in coverage for nutrition services for obesity/
overweight may be a reflection of:
A. insurance industry mergers
8
codes
D. Verify a payer’s coverage or
reimbursement for the MNT
service
7. Which of the following MNT
CPT codes would be used for a
face-to-face follow-up visit with
an obese 57-year-old female?
A. 97802
B. 97803
C. 97804
D. None of the above
8. Helpful resources to assist
with MNT reimbursement
found through ADA’s Web site,
www.eatright.org, include all of
the following EXCEPT:
A. a third-party payer brochure
with strategies to increase coverage of RD-provided nutrition
services
B. marketing tools for RDs
to increase MNT coverage
and consumer access to MNT
services
C. a comprehensive listing of
private insurance companies
and other payers with their specific coverage policies for MNT
D. interactive online tool for
ADA Reimbursement Community of Interest members
Chair’s
Column
Monica Krygowski,
MS, RD, LD, is the
2007–2008 Weight
Management DPG
chair. Contact her at
monica.krygowski@
uchsc.edu.
A brief update on our strategic plan
W
9
for information.) You might also look
at the Awards and Honors Section (page
24), too, for information about the Excellence in Weight Management Practice
Award application information. See, I
told you this would get good.
The second goal is to empower members to compete successfully in the field
of weight management. The continuing
professional education units (CPEUs)
offered in each newsletter, the regularly
updated Web site, and the two professional development stipends to attend
the Annual Weight Management Spring
Symposium (Nashville, Tenn. April 4-6,
2008) help accomplish this goal. See
page 16 or go to the WM Web site (www.
wmdpg.org) for more information and
eligibility about the professional development stipends being offered.
The third goal is to support research
initiatives. To that end, WM continues to
fund the Dietetic Practice-Based Research Network (DPBRN). Additionally,
WM funded two members to attend The
Obesity Society’s Annual Scientific Meeting this past October and will continue
to do this each year.
Finally, goal four is to influence key
decision-makers in the weight management arena. To meet this goal, WM is
offering a professional development stipend to the Public Policy Workshop to be
held Feb. 4-6, 2008 in Washington, D.C.
Now that you’ve made it to the end of
my column, let me make a final request
of each of you. When you receive your
ballot for ADA and for the DPGs of
which you are members, please take the
time to go on-line and vote. And how
about volunteering in one of your DPGs
to share your talents? Then one day you,
too, can be looking for your muse as you
write your chair’s column.
Volume 5, Number 3, Winter 2007-2008
riting newsletter columns
is not my strong suit. So
in looking for my muse,
I sought out the one document that
defines our mission as a dietetic practice
group (DPG)—the strategic plan. Now,
before you go on to the next article,
please read on for a few more sentences.
This may get pretty good. You see, in
reviewing the strategic plan, I realized
the amazing creativity that our Executive Committee (EC) has exhibited in
meeting some of our goals. For example,
the first goal is to build an aligned,
engaged and well-informed membership. So, it naturally flowed that one of
the objectives to meet this goal must be
to improve retention and increase our
membership. As of this week (mid October 2007), Weight Management (WM)
membership is at 4,572, making WM
the third largest DPG in the American
Dietetic Association (ADA). By the time
this gets to print, these numbers will have
changed, but you get the point.
Now for the creative part ... Thanks to
the Member Retention and Recruitment
Committee and to its Director, Michele
Doucette, PhD, WM was one of three
DPGs to institute reduced rates for students—$15 for the year—and to debut
this at Food & Nutrition Conference &
Expo 2007. Other DPGs are now following our lead, and because of this, we all
win. The students get more in-depth information about dietetics, and as a result,
we grow stronger as a profession.
Also related to the first goal is the
increase in blast e-mails to keep you
abreast of opportunities both in the DPG
and in ADA. Please also note that there
are more stipends and scholarships offered this year. (See page 12 in this issue
Have You Moved?
If you have recently moved or had a change of name,
please update your membership information with the
American Dietetic Association (ADA) to ensure that you
don’t miss out on any WM newsletters or other communications. Because ADA maintains our address data, you
must notify the association directly before you move, or
your WM newsletters may be delayed. To update your
member profile information you may:
n Use ADA’s Web site (www.eatright.org) and
Member Profile secured server. Using your member
ID number and Web password, which was provided to
you on your ADA membership card, view your existing
member profile at the Online Business Center, make
necessary changes, and submit changes to update
ADA’s records immediately.
n Print a change-of-address form from ADA’s Web site
(www.eatright.org/addresschange.html), complete
the form, and fax (312/899-4899) or mail to American
Dietetic Association, Attention: Membership Team,
120 South Riverside Plaza, Suite 2000, Chicago, IL
60606-6995.
n Mail in the Change-of-Name and/or Address card
found in the back of each Journal of the American
Dietetic Association.
CPEU answer key
See the continuing professional education
article on page 4 and the credit selfassessment questionnaire on page 8.
2. C 3. D 4. C 5. A 6. D 7. B 8. C
Newsletter information
Weight Management Newsletter is
the official publication of the Weight
Management (WM) Dietetic Practice
Group (DPG) of the American Dietetic
Association (ADA). It is published
quarterly and is distributed to over
4,500 dietetics professionals working
in weight management. Members of
the DPG Executive Committee as well
as expert content reviewers review
all articles. Mention of product names
in this publication does not constitute
endorsement by the ADA or the WM
DPG. © 2007.
Upcoming deadlines:
Spring 2008 issue
Articles due by Jan. 22, 2008
Summer 2008 issue
Articles due by April 22, 2008
All materials should be sent to
mwangsgaard@jennycraig.com
Subscription year is from June 1 to
May 31.
31
Weight Management Newsletter
is mailed Standard Class (aka., 3rd
class) mail and as such is not forwarded by the United States Post
Office. Please keep your contact
information updated with ADA by calling 800/877-1600 ext. 5000 to receive
newsletters even after you move or
change your name.
Please contact Paula Peirce at
ppeirce@aol.com if you are missing
issues.
Volume 5, Number 3, Winter 2007-2008
1. C
n E-mail changes to the ADA Membership Team at
membrshp@eatright.org.