Weight Management Counseling: A Guide to Understanding Coverage, Reimbursement,
and Opportunities for Registered Dietitians
By Pam Michael, MBA, RD and Suzanne Brodney Folse, PhD, RD
Reprinted with Permission from the Weight Management Matters, Fall 2008, volume 6,no.2; A publication of the
Weight Management DPG.
Learning Objectives
After reading this article the reader will be able to:
1. Describe the medical nutrition therapy current procedural terminology (CPT) codes and
identify when each should be used.
2. Describe the process to become a credentialed provider with a healthcare provider.
3. List five resources to assist with medical nutrition therapy reimbursement that can be found
on the American Dietetic Association (ADA) Web site (www.eatright.org).
Is 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 between 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 medical
nutrition therapy (MNT) services, essential for improving weight and overall health, is less
apparent and varies 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 healthcare system. A recent report from the
President’s Cancer Panel noted, “The links between cancer, diet, and obesity have not been
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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 American Dietetic Association (ADA) Coding
and Coverage Committee indicated approximately 18% of RD survey responders (n=1589)
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).
Sidebar
Incident to services under Medicare Part B are defined by the Centers for Medicare & Medicaid
Services (CMS) as services that are:
•
An integral, although incidental, part of the physician's professional service
•
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
•
Of a type that are commonly furnished in physician's offices or clinics
•
Furnished by the physician or by auxiliary personnel under the physician's supervision (4)
2
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).*
*Footnote:
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.
Fitzner et al. reported results of an ADA environmental scan of selected health plans to assess
the plans’ coverage policies, perceptions and expectations of dietetic 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 findings were not intended to represent all managed care organizations or the
healthcare 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).
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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 benefit is
limited to MNT provided by licensed (as applicable) RDs for qualifying individuals with
diabetes and non-dialysis 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 services 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.
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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
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 to a person of normal weight (9,10). Jans et al. reported that obese employees
were absent 14 days a year 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 they now include 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 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
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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 or dietetic practice group who serve as resources for
local coverage information as well as coding and Medicare MNT-related 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 provided services for obesity/overweight/abnormal weight gain. The chart 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):
o Anthem (Blue Cross and Blue Shield of New Hampshire) for “overweight” and
“abnormal weight gain”
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o Harvard Pilgrim Healthcare (in New Hampshire) for “morbid obesity”
o Care 1st Blue Cross Blue Shield (in Virginia) for “obesity”
o Aetna (in Virginia) for “obesity” and “overweight”
o Cigna Health Plan and Vytra Health Plans (in New York) for “abnormal weight
gain”
o BlueCross BlueShield of Northeastern Pennsylvania: part of the plan’s disease
management weight management program for adults and children (> 2 years old)
o BlueCross BlueShield 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 January 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:
•
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
•
Children: Body Mass Index (BMI)-for-age percentile equal to or greater than the 85th
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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 plan 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.
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 http://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.
Aetna
Affinity Health Plan
Blue Cross Blue Shield of Massachusetts
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Blue Cross and Blue Shield of North Carolina
Empire Blue Cross Blue Shield
HealthPartners
Highmark, Inc.
Horizon Blue Cross Blue Shield
Kaiser Permanente
Premera Blue Cross
WellPoint Health Networks
CPT and HCPCS Codes Applicable for Obesity and Other Diseases
In 2000, ADA submitted a MNT code proposal to the American Medical Association (AMA)
Current Procedural Terminology (CPT) committee, the national association who 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 encounters
(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.
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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.
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 self-manage 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 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.
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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
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 codes, or the
International Classification of Diseases, Ninth Revision, are the official code system used for
tracking disease/condition incidence in all health care settings in the U.S.
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 denied. The ICD-9 codes for Obesity and Overweight are presented in Table
4.
Becoming a Credentialed Provider with a Payer
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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 RD-provided nutrition
services such as MNT. Some payers have indicated they pay RDs based on a certain percent
above the 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 procedures 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
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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 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).
•
Third party payer brochure. Does your local insurance payer know an investment in the
services of an RD today can save them money tomorrow? Use this new brochure, produced
by ADA and Commission on Dietetic Registration (CDR), to increase coverage of RDprovided nutrition services.
•
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.
•
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 dietetic professional considering private practice. By incorporating checklists, selfassessments, 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
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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.
•
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.
•
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 at www.eatright.org under the “Governance” tab.
•
The Weight Management and other ADA dietetic practice groups (DPGs) have resources to
aid members with reimbursement issues.
o Members 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.
o Members 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 their Web page at http://www.nedpg.org/.
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•
ADA staff from the Nutrition Services Coverage Team are another resource for code,
coverage and compliance information. Contact ADA staff at reimburse@eatright.org.
•
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 Nutrition Practice Guidelines to apply cutting-edge, synthetic
research to practice. For additional information go to the ADA Evidence Analysis Library at
http://www.adaevidencelibrary.com/.
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:

Increase demand for and utilization of services provided by members

Empower members to compete successfully 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
15
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 dietetic practice groups 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.
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?
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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 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-ofpocket 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 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 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.
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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 involved, 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 to 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 non-dialysis 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
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insurance coverage is available, Mrs. Smith would need to pay out-of-pocket 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 above for more information on “incident to” services.
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Table 1
MNT Current Procedural Terminology (CPT) Codes
97802: MNT, initial assessment and intervention, individual, face-to-face, each 15 minutes
97803: MNT, reassessment and intervention, individual, face-to-face, each 15 minutes
97804: MNT, group, 2 or more individuals, each 30 minutes
CPT codes, descriptions and material only are copyright ©2007 American Medical Association.
All Rights Reserved. CPT 2006 Current Procedural Terminology.
Table 2
Healthcare Common Procedure Coding System (HCPCS or “S”) Codes
S9470: Nutritional counseling dietitian visit
S9465: Diabetic management program dietitian visit
S9452: Nutrition classes non-physician provider, per session
S9449: Weight management classes non-physician provider, per session
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 healthcare 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 selfmanagement 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).
• 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.
• 98961: 2-4 patients
• 98962: 5-8 patients
The purpose of the educational and training services is to teach the patient (may include
caregiver(s)) how to effectively self-manage the patient’s illness(s)/disease(s) or delay disease
comorbidity(s) in conjunction with patient’s professional healthcare 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.
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Table 3
Education and Training for Patient Self-Management CPT Codes, continued
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 healthcare professional society/association, or other appropriate
source.
• For counseling and education provided by a physician to an individual, see the appropriate
Evaluation and Management codes
• For counseling and education provided by a physician to a group, use 99078
• For counseling and/or risk factor reduction intervention provided by a physician to patient(s)
without symptoms or established disease, see 99401-99412
• For medical nutrition therapy, see 97802-97804
• For health and behavior assessment/intervention that is not part of a standardized curriculum,
see 96150-96155
CPT copyright 2007. American Medical Association. All rights reserved. CPT is a registered
trademark of the American Medical Association
Table 4
Diagnosis Codes for Obesity and Overweight
278.0: Overweight and obesity
Use additional code (V85.0-V85.54) to identify Body Mass Index (BMI), if known
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
 278.01: 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
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.
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Table 5
MNT Coverage Advocacy Work: Seven Steps to Make a Difference in Your Career and
Your Clients’ Lives
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 10 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, their annual reports, and past interactions with
RDs (e.g., amount spent on medications, where the plan is targeting care for certain highrisk/high-cost diseases/conditions, like disease management programs for certain conditions).
Know 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 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, etc.).
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 payor’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. Send a thank-you note and summary of next steps.
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References
1. Anderson GF, Frogner BK, Reinhardt UE. Health spending in OECD countries in 2004: an
update. Health Affairs. 2007;26:1481-1489.
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;100:1530-1535.
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;106:1349-1353.
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;49:975980.
12. Israel D, McCabe M. Using disease-state management as the key to promoting employer
sponsorship of medical nutrition therapy. J Am Diet Assoc. 1999;99:583-588.
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Bios
Pam Michael, MBA, RD is director of the American Dietetic Association 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.
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