Understanding Medical Nutrition Therapy Coverage for Patients

Medicare covers medical nutrition therapy (MNT) services, but only under certain circumstances. 

To put it succinctly, they cover these services if a patient has diabetes or kidney disease, or a patient has had a kidney transplant in the last 36 months. Additionally, a doctor must refer a patient for these services. 

Sometimes a doctor recommends a patient receive nutrition services at a frequency that is greater than what Medicare will cover. Or, they might recommend types of nutrition services that Medicare doesn't cover. When that is the case, the patient may have to pay some or all of the costs and the ABN (advance beneficiary notice) process might need to be applied. Stay tuned for an upcoming Compliance Conversations podcast for a deeper discussion on ABNs. 

Most Medicare Administrative Contractors (MACs) provide guidance on MNT coverage. For example, Noridian Healthcare Solutions (Noridian) provides some of the following guidance on their website.  

Some of the MNT codes to consider include:

97802 - Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with patient, each 15 minutes (Note: Use code for initial visit only) 

97803 - MNT; re-assessment and intervention, individual, face-to-face with patient, each 15 minutes 

97804 - MNT; group (two or more individuals), each 30 minutes 

G0270 - MNT; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease), individual, face to face with the patient, each 15 minutes (Note: Use code when there is a change in beneficiary's condition) 

G0271 - MNT; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition, or treatment regimen (including additional hours needed for renal disease) group (two or more individuals), each 30 minutes (Note: Use code when there is a change in beneficiary's condition) 

But understanding the codes alone is often not enough to ensure coverage and/or compliant billing practices. Some of the coverage guidelines shared by Noridian, for example, include: 

• During the initial calendar year, three hours of MNT are covered. Two hours each calendar year are covered during subsequent years. Unused hours cannot be carried over to the next year.  

The coverage criteria are: 

• Primary care physician or specialist coordinating care for the beneficiary must make a referral and indicate a diagnosis of diabetes, renal disease or receiving a kidney transplant within last 36 months 
• A registered dietician (RD) or nutrition professional must provide services 
• Number of hours covered in episode of care cannot be exceeded unless a second referral is received from treating physician 
• Services may be provided in either a group or individual setting 
• DSMT (Diabetes Self-Management Training) and MNT services can be provided within the same time period and a maximum number of hours allowed under each benefit are covered. [Only exception is that DSMT and MNT cannot be provided on same day to same beneficiary]
• Every calendar year, beneficiary must have new referral for follow-up hours
• Referrals may only be made by treating physician 

These guidelines ultimately come from Medicare’s National Coverage Determination (NCD) 180.1 (see here: https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?NCDId=252).  

The NCD clarifies that according to the exception found at 42 4CFR 410.132(b)(5) (https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-410/subpart-G/section-410.132), additional hours are considered to be medically necessary and covered if the physician determines that there is a change in medical condition, diagnosis, or treatment regimen that requires a change in MNT and orders additional hours during that episode of care.

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