Correct Billing for Medicare Part B MNT

[Excerpt from the January 2003 The Medicare MNT Provider, the monthly ADA newsletter on Medicare issues and regulations.]

Correct Billing for Medicare Part B MNT
Marie Infante, JD

Last January 1, Medical Nutrition Therapy became a distinct Medicare Part B benefit covering Medical Nutrition Therapy services when provided by registered dietitians or nutrition professionals to Medicare beneficiaries with diabetes or renal disease.  Registered dietitians and nutrition professionals are now permitted to bill Medicare Part B for the provision of Medical Nutrition Therapy services.  However, as with all Medicare benefits, Medical Nutrition Therapy is subject to extensive regulation by the Centers for Medicare & Medicaid Services (CMS) and it is important when billing Medicare Part B for this benefit to comply with all applicable regulations. 

The Medicare Medical Nutrition Therapy benefit provides coverage for medical nutrition services when administered to beneficiaries with diabetes or renal disease.  CMS defines "diabetes” as diabetes mellitus type I and II and includes gestational diabetes.  The diagnostic criterion for a diagnosis of diabetes is a fasting glucose greater than or equal to 126 mg/dL.  The criteria for gestational diabetes is any degree of glucose intolerance with onset or first recognition during pregnancy.  “Renal disease” is defined as “chronic renal insufficiency, end stage renal disease when dialysis is not received, or the medical condition of a beneficiary for 36 months after kidney transplant.”  Chronic renal insufficiency is defined as “the stage of renal disease associated with a reduction in function not severe enough to require dialysis or transplantation (glomerular filtration rate [GFR] 13-50 ml/min/1.73m2).

For Medical Nutrition Therapy appropriately provided after January 1 to beneficiaries with diabetes or renal disease, registered dietitians and nutrition professionals, who are enrolled as Medicare providers, must bill Medicare utilizing their own provider identification number (PIN).  Registered dietitians and nutrition professionals may elect to reassign their Medicare reimbursement to the hospital or physician clinic where they are employed and authorize their employer to bill Medicare on their behalf.

In either scenario, the registered dietitian or nutrition professional must individually enroll in the Medicare program and obtain their own PIN in order to receive Medicare reimbursement for the provision of Medical Nutrition Therapy services.  If in the same calendar year three hours of covered MNT services have been provided and additional hours are medically necessary, documented by the physician and indicated in a physician referral, RDs should use an Advanced Beneficiary Notice (ABN) prior to proving additional MNT services to qualifying Medicare beneficiaries. 

Registered dietitians and nutrition professionals may not bill Medicare Part B for Medical Nutrition Therapy services provided to beneficiaries for diseases other than diabetes and renal disease.  An ABN is not required since other diagnosis are not covered by Medicare Part B.  In this case, for diseases not covered by Medicare, the RD can bill the patient or other insurers, not the Medicare carriers.  If no other insurance coverage is available, the patient would pay out-of-pocket for Medical Nutrition Therapy services provided for other diseases and conditions.

Medical Nutrition Therapy services cannot be billed for as “incident to” physician services.  This prohibition applies to Medical Nutrition Therapy services provided prior to January 1, as well as to services provided after January 1, and to all diagnosis, including diabetes and renal disease.  Medicare reimburses “incident to” services only to the extent the services would otherwise be covered by Medicare. 

Prior to the beginning of 2002, medical nutrition therapy services were not a covered Medicare benefit otherwise reimbursable by Medicare and, therefore, should not be billed as “incident to” services.  With respect to Medical Nutrition Therapy services provided after January 1, there is specific guidance from CMS clearly stating that Medical Nutrition Therapy services “cannot be paid ‘incident to’ physician services.”  All Medical Nutrition Therapy services provided after January 1, must be billed to Medicare Part B utilizing the registered dietitian’s or nutrition professional’s PIN and not as “incident to” physician services.

Additionally, CMS has recently confirmed that “incident to” billing requires statutory authority and because registered dietitians and nutrition professionals do not have the appropriate authority they are not permitted to bill for “incident to” services.  Registered dietitians and nutrition professionals should not bill for any other services they provide as “incident to” the provision of Medical Nutrition Therapy services. 

Dietetics professional also need to be aware that CMS has recently stated that while there is some confusion caused by several Diabetes Outpatient Self-Management Training (“DSMT”) program memoranda that were published prior to the final DSMT regulations, it is CMS’ current position that certified DSMT programs are stand alone programs and cannot be billed as “incident to” services.  So, the entity accredited as the DSMT program should bill Medicare using the appropriate DSMT G codes for all components included in the DSMT program. 
 
As can be seen, the Medicare Part B Medical Nutrition Therapy benefit is highly regulated by CMS and appropriately billing Medicare Part B for the service can be complicated.  However, there are several basic principles which should help to clarify the Medicare billing requirements. 

  • Registered dietitians and nutrition professionals must either bill Medicare Part B 
    utilizing their own PIN or reassign their Medicare reimbursement.  
      
  • Medicare should only be billed for Medical Nutrition Therapy that is appropriately 
    provided to beneficiaries with diabetes or renal disease because no other 
    beneficiaries are eligible for the benefit. 
     
  • Medical Nutrition Therapy should not be billed for as an “incident to” service and 
    registered dietitians and nutrition professionals are not permitted to bill for any 
    other services as “incident to” Medical Nutrition Therapy services.