Introduction to Medical
Nutrition Therapy
NFSC 470
Nutrition Care Process
Process of planning for and meeting MNT needs
of the individual
1. Assessing nutrition status and analyzing data to
identify nutrition related problems
2. Coming up with a nutrition diagnosis
3. planning & prioritizing nutrition intervention(s)
to meet the patient’s needs
4. Evaluating the nutrition care outcomes
Medical Nutrition Therapy
• The use of specific nutrition interventions
to treat an illness, injury or condition.
Standards of Care
Standards of care: treatment guidelines that
specify appropriate treatment protocols based on
scientific evidence, and collaboration between
medical professionals involved in the treatment
of a given condition.
Example:
• Treatment standards applied within public
hospitals to insure that all patients receive
appropriate care regardless of financial means.
MNT Protocols
• MNT protocols are a set of steps
incorporating current professional
knowledge (evidence-based) that clearly
define the level, content and frequency of
nutrition care appropriate for a disease or
condition.
MNT PROTOCOLS – SAMPLE
TOPICS
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Nutrition Assessment
Nutrition Risk Levels
Referrals to Nutrition Care Professional
Supervision of Nutrition Documentation
Providing Therapeutic Diets
Height/Weight Monitoring
Significant Weight Loss Protocol
Calculating Nutrition Needs
Pressure Sores
Dysphagia
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Pernicious Anemia Vitamin B12 Deficiency
Megaloblastic Anemia
Folate Deficiency
Respiratory Diseases
Cardiovascular Disease
Cerebrovascular Disease
Cancer
Clients on NPO
Enteral Nutrition
Total / Peripheral Parenteral Nutrition
Gastrointestinal (GI) Disorders
Liver disease: hepatitis & cirrhosis
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Who makes sure the standards of care are met and
appropriate protocols are followed?
JCAHO:
What is JCAHO?
• Independent, not-for-profit organization
• Governed by a board that includes physicians,
nurses, and consumers
• Sets standards of patient care
• Evaluates the quality and safety of care for more
than 15,000 health care organizations
• To maintain and earn accreditation, JCAHO
conducts an extensive on-site review at least once
every three years. JCAHO evaluates the
organization's performance in areas that affect
patient care.
• Accreditation is awarded based on how well the
organizations met Joint Commission standards.
Patient Screening for Malnutrition or
Need for Nutrition Intervention
JCAHO: screen for nutrition risk within 24
hours of admission
– I.e.
– Nutrition “triggers” indicate need for more
intensive nutrition assessment:
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• Within
• Enloe re-screens right away by
• Examples of screening criteria:
– Over age 80 automatically = moderate risk
– Diagnosis:
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renal failure = moderate risk
trauma and ICU = high risk
Peds in ICU = high risk
Ventilated pt. in ICU = high risk
• Risk level is established based on screening
criteria until RD assesses the patient.
• Then, it’s a point system to determine
actual risk level, with diagnosis, dietary
intake, albumin, and wt status all
considered to be worth a given number of
points.
• The points are added up to determine
nutrition risk level for the purpose of
prioritizing who will be seen first and most
frequently.
Case Example
Influences on Nutrition Care
• Managed care
– A concept based on an effort to control escalating
health care costs by the health insurance industry
– Defines a “reasonable maximum fee” which health
care providers may charge for any given service
– Providers have to accept these maximum fees if they
wish to be listed in directories of “approved”
physicians of specific insurance companies.
Types of Managed Care Organizations
1. Health Maintenance Organization (HMO)
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Insurance company controls all aspects of the health care
of the insured.
Each member is assigned a primary care provider (PCP)
who is responsible for the overall care of members
assigned to him/her.
Pt. must obtain a referral from the PCP to see a specialist.
PCP must authorize non-emergency hospital admissions
Typically, services are not covered if performed by a
provider not specifically approved by the HMO, unless it
is an emergency situation as defined by the HMO.
Since the 1980s, HMOs have been protected by Federal
law from malpractice litigation on the grounds that the
decisions regarding patient care are administrative rather
than medical in nature.
2. Preferred Provider Organization (PPO)
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Policy-holder is free to choose his/her own physician
Better benefits if a PCP (from the approved “network”) is
seen
“Network" caregivers and facilities are independent of
insurance company ownership, and may hold contracts
for reimbursement with multiple insurors.
"Pre-certification" (prior approval) may be required
before nonemergency hospital admissions, testing,
consultations or outpatient surgery under many plans.
Providers remain liable for malpractice.
PPO provders hold contracts with insurance companies,
under which they agree to accept the reimbursement that
was negotiated at rates agreed upon between themselves
and the insuror.
3. Federal Insurance Plans
a. Medicare –
Part A: ______________________________
• Medicare's Part A helps to cover hospital stays, skilled
nursing facility care, some home health care, and
hospice care.
Part B: _______________________________
_____________________________
• Medicare's Part B helps to cover doctors' services,
outpatient hospital services, and other medical services
not covered by Part A, such as home healthcare.
(Monthly Premium: $88.50/month in 2006)
b. Medicaid –
Federal program, but run by individual
states so wide variation in eligiblility
When is MNT a covered health
insurance benefit?
• Medicare, MediCal and private insurers may cover
MNT when determined to be reasonable and medically
necessary.
• The RD must be acting upon referral from a physician
with a “prescription” for assessment and counseling for
a nutrition-related diagnosis.
• International Classification Diseases (ICD-9CM) codes
are used to identify different diagnoses such as diabetes
and hypertension. The diagnoses codes are selected by
the referring physician.
• Insurance plans are required by California law to
cover Diabetes Self-Management Training
(DSMT)
– MNT provided by an RD or qualified nutrition
professional.
– Medi-Cal may cover DSMT/MNT but is not required
to.
• Medicare part B covers MNT for
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Type 1 and Type 2 Diabetes
Gestational Diabetes
Non-Dialysis Kidney Disease
Post renal transplant (6 to 36 months)
with the RD as a Medicare provider.
What are ICD-9-CM Codes?
• The International Classification of
Diseases, 9th revision, Clinical Modification
codes, developed by WHO are medical and
surgical diagnosis codes. (revised each year)
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• Many codes require extensions to clarify
the diagnosis:
– 272.0 for
– 272.2 for
What are Current Procedural Terminology
(CPT) Codes?
• CPT codes are procedural codes developed by the
AMA for professional billing.
• Billing codes for MNT:
– 97082 = initial assessment and intervention, faceto-face with the patient. Each billed unit is 15
minutes.
– 97083 = reassessment and intervention, face-to-face
with the patient. Each billed unit is 15 minutes.
– 97084 = a group visit of 2 or more individuals.
Each unit is 30 minutes.
Study demonstrates MNT costsavings
Cost-Savings MNT Outcomes study (Illinois
Dietetic Assoc.) determined cost-savings
and cost-prevention realized within two
years of an initial MNT visit provided by
an RD. The results, based on 42 patient
outcomes, show that MNT can have the
following impact and average cost savings
per patient:
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reduction of rx meds
reduction in lab, other tests
reduction in MD office visits
reduction in # of hospitalizations
reduction in emergency room visits
$1,052
$ 654
$ 505
$4,960
$2,400
The study also demonstrates that MNT can save
insurers and employers $19, 305 per patient.
Total estimated dollars saved when coupling costsavings with cost-prevention ranged from $220
to $70,420 per patient.
Shows the value of documenting MNT patient
outcomes, which are strongly needed to build the
case for nationwide MNT coverage.
Review of Medical Charting
• Medical record = legal document
– Communication among members of health care team.
– Confidentiality
– POMR
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Computer or black ink
Chronological order
Institution’s accepted abbreviations
Signature, and actual date and time of entry
Professionalism
Corrections/addendums
• If you didn’t chart it, you didn’t do it.
• Never chart for another person.
• Confidentiality issues
– Verbal, written, electronic
– Legal penalties
– Disciplinary action by hospital
Writing a SOAP Note
• Subjective
– Information pt. or caregiver/family tells
you, what you observe but haven’t
measured.
– Significant nutritional history
• Appetite, home diet practices, chewing and
swallowing ability, N/V/D, etc.
– Pertinent socioeconomic, cultural info
– Level of physical activity
• Objective
– Factual, reproducible observations
(anthropometric and lab data)
– Dx. And pertinent medical history
– Age, gender, height, weight, %IBW, etc.
– Desirable weight/weight goal
– Labs (pertinent)
– Diet order/nutrition support (current diet
provides…)
– Meds (pertinent)
– Calculated nutrient needs (may also go under “A”
• Assessment
– Your assessment of pt. nutritional status based
on S & O data
• If you make an assessment statement in
“A,” the information has to be under “S”
or “O.”
Example: pt. w/mod. depleted visc. prot.
stores per alb level (must be listed under ‘O’).
– Do not repeat lab values in assessment (“alb.
Of 3.0 indicates…” No-no)
– Evaluation of pertinent nutritional history
– Assessment of labs
– Assessment of patient’s comprehension and
motivation, if appropriate
– Assessment of the diet order and/or feeding
modality
– Anticipated problems and/or difficulties for
patient compliance or adherence
• Plan
– Diagnostic studies needed
– Suggestions for gaining further pertinent
data
– MNT goals
– Recommendations for nutrition care and
nutrition education
– Recommendations for other health care
providers
– Specific parameters you will monitor
– Plan for follow-up (time frame)
This is your plan to improve nutritional status or
make recommendations to the doctor
examples:
1. Educate pt. on 1500 kcal diabetic diet
2. Provide Ensure w/meals TID
3. Recommend MVI q day
4. Provide food preferences (list specific
changes)
5. Recommend increased TF rate
to 75cc/hr.
6. Monitor ______ (labs)
7. Follow-up in 2 days
Other documentation styles:
• DAR – diagnosis, assessment,
recommendations
• PIE – problem, intervention, evaluation
• PGIE – problem, goal, intervention, eval.
• (content is the same regardless of recording
style)