Billing Medicare for MNT and DSMT Services

MNT and DSMT cover similar topics in the initial assessment and training (the MNT assessment is more in-depth) and are coordinated benefits under Medicare.

MNT Services

Medicare covers MNT services when furnished by a registered dietitian (RD) or nutrition professional. "Registered dietitian or nutrition professional," means a dietitian or nutritionist licensed or certified in a state as of December 21, 2000; or an individual who on or after December 22, 2000:

• Holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics as accredited by an appropriate national accreditation organization recognized for this purpose; and
• Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional; and
• Is licensed or certified as a dietitian or nutrition professional by the state in which the services are performed. In a state that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a "registered dietitian" by the Commission on Dietetic Registration or its successor organization, or meets the requirements of the first two bullets of this section.

When billing MNT services, remember that:

• The benefit is available for beneficiaries with diabetes or renal disease when a physician (as described in the Social Security Act) makes a referral. (This is different from DSMT where either a physician or a qualified non-physician practitioner may make the referral for DSMT services.)
• The MNT benefit allows for renal and diabetes patients to receive three (3) hours in the initial year and two (2) hours in subsequent years for follow-up.
• The MNT service is coordinated but separate from the DSMT benefit.
• Medicare will cover fully MNT in the same episode of care as DSMT up to their specified limits in the initial year, but MNT and DSMT must be provided on different days. This is because the two benefits provide different behavioral modifications techniques (i.e., classroom study for basic knowledge and individual attention that focuses on results over time) which may prove to be complementary.
• The three hours allowed for MNT coverage can be spread over any number of visits, but each visit must be a minimum of 15 minutes since billing is in 15-minute increments.
• Medicare will rely on the referring physician to determine the medical need for a beneficiary to receive both MNT and DSMT in the same year for follow-up services.

The procedure codes for MNT are:

New MNT Codes:

Two new G codes have been created for MNT when there is a change in condition of the beneficiary:

The above new G codes for additional hours of coverage should be used after the completion of the 3 hours of basic coverage under 97802-97804 when a second referral is received during the same calendar year. No specific limit is set for the additional hours. Contractors will use dietary protocols from the American Dietetic Association and the National Kidney Foundation as guides if local medical review limits are established for the additional hours of coverage.

These new codes will be part of the annual 2003 HCPCS update. Therefore, the codes will be effective for dates of service on or after January 1, 2003. [EM 2002-1087/CR 2373]

NOTE: The MNT benefit is only payable when billed to Part B carriers. No claims should be sent to Fiscal Intermediaries.

DSMT Services

Medicare covers these services when they are furnished by a certified provider who meets certain quality standards. The training must be ordered by the physician or qualified non-physician practitioner treating the beneficiary's diabetes. The program providing the DSMT must be certified by the American Diabetes Association (ADA) or the Indian Health Service (IHS).

The Centers for Medicare and Medicaid Services (CMS) has ruled that DSMT can be rendered in a local health department. Health departments, which have a Medicare provider number and are ADA certified, are permitted to bill the Medicare Part B carrier for DSMT. However, it is essential that a physician or qualified non-physician practitioner must first make a referral for the beneficiary requesting diabetes training. A physician referral is separate and distinct from the "incident to" requirements. Therefore, the "incident to" rule is not applicable for DSMT because this is a "stand alone" benefit.

When billing DSMT remember that:

• Beneficiary is eligible to receive 10 hours of initial training within a continuous 12-month period.
• The 12-month period is a rolling calendar (beginning with the date of first service.)
• Up to nine hours of initial training must be provided in a group setting consisting of two to 20 individuals.
• One hour of training may be provided on an individual basis for the purpose of conducting an individual assessment and providing specialized training.
• If any special condition or circumstance exists that makes it impossible for a beneficiary to attend a group training session that beneficiary may attend individual training as long as individual training has been requested by the physician or qualified non-physician practitioner treating the beneficiary's diabetes.
• Two hours of follow-up training is covered each year starting with the calendar year following the year in which the beneficiary completes the initial 10 hours of training. The two hours of training may be given in any combination of half-hour increments within each calendar year on either an individual or group basis without the certification of the ordering physician or non-physician practitioner that special conditions exist.

The procedure codes for DSMT are:

NOTE: Payment rates are based on a 30-minute session for the above codes. For billing prior to January 1, 2002, if a one hour session of diabetes education has been performed, bill code G0108 or G0109 with a "1" in the units column. Even though the definition of the codes reads 30 minutes, the rate the provider will receive is for 60 minutes. For providers that perform a 30-minute service, they should not bill until a full hour is completed and should use as the date of service, the day the hour was completed. Providers that bill for a one hour session must use a "1" in the units column and not a "2." For billing on or after January 1, 2002, put the correct number of units in the units column. For example, if a provider bills for a 30-minute session then a "1" must be in the units column. For an hour session a "2" must be in the units column and for a two-hour session a "4" must be placed in the units column.

Effective for dates of service on or after April 1, 2002, Common Work File (CWF) will track the number of hours of DSMT and MNT. Contractors will review claims when a beneficiary has received over the maximum number of hours of training allowed under DSMT or MNT.