Places of Service and Specific Healthcare Services
This section provides information about how health insurance payments generally occur when medical nutrition therapy is provided outside of a hospital inpatient setting (office and other places of service) or when MNT and/or other services are provided as part of other medical benefits for specific health care services, such as home health, cardiac rehabilitation, skilled nursing services, palliative care and hospice. References to MNT in this content are about the intervention unless the Medicare MNT (Part B) benefit is specified. Understanding how health insurance payments for specific health care services are structured and/or how claims are submitted to payers, such as Medicare, Medicaid, private insurers can help RDNs support the financial sustainability of the services they provide.
What, how and/or where are important variables that may determine how health insurance payments occur from payer to providers or organizations.
Medical nutrition therapy is a service that may be eligible for reimbursement from health insurance providers (payers) when it is provided according to individual benefits and coverage, and when provided in an approved place of service or delivery modality (e.g., telehealth). Some specific places of service, such as Federally Qualified Health Centers, Tribal facilities, Rural Health Centers, and Critical Access Hospitals, have their own unique payment methodologies that determine potential payment for MNT.
Payments for other health care services, such as home health and skilled nursing services, are structured in yet another way, thereby affecting the payment stream for services provided by the RDN. Understanding the payment streams as well as goals around care can help RDNs understand how their services are paid for as well as opportunities to add value in each environment.
Lastly, different payment models used in the U.S. health care system may further influence how payments from payer to provider organizations occur. Alternative payment models (APMs) or value-based payments (VBPs) are examples of other payment models. When APMs/VPBs are used, payments work differently than as described in this section, as they are tied to quality, outcomes, and the cost of care. RDNs working in organizations using VBPs can clarify whether MNT is factored into the value-based payments, or if MNT falls outside of those arrangements and fee-for-service payments apply. For more information see alternative payment models and value-based-care.
Places of Service
The following sections include information about how payment for MNT occurs in these specific places of service:
One example of a specific Place of Service is "office." There are several settings that may be considered office (POS code 11), including private practice offices of dietitians, primary care and specialist physicians, and other providers. There may be other settings that a payer will consider as an "office" place of service. Registered dietitian nutritionists should inquire with individual payers about the ability to provide MNT in specific settings and locations.
When MNT is provided in an office, a CMS 1500 claim form is used to submit claims for professional services. Payments are made to individual providers, practices or organizations. Payments, claims processes and place of service codes are different in offices that are part of hospital-based departments.
Federally Qualified Health Centers (FQHCs) are health centers or clinics that qualify for funding under Section 330 of the Public Health Services Act (PHS) and meet specific Centers for Medicare & Medicaid Services criteria. Federally Qualified Health Centers are reimbursed through a unique payment system with Medicare and Medicaid called the FQHC Prospective Payment System (PPS).
Many different types of health centers may meet CMS criteria for FQHC status, including health centers that receive recurring funding or limited grants from the Health Resources & Services Administration (HRSA), Community Health Centers (CHCs), Migrant Health Centers, Health Care for the Homeless, some university clinics, and Health Care for Residents of Public Housing, and tribal clinics (Note: Tribal FQHCs use a separate Prospective Payment System). Health centers can be located in rural or urban areas, and provide care to populations with Medicare, Medicaid, private/commercial insurance and without health insurance.
Understanding whether a health center meets FQHC criteria, as well as the payer mix of the patient population, is important to understanding how payments are allocated to a health center for services provided by RDNs.
- Learn more about the Academy's call to action regarding the integration of MNT for adults in HRSA-funded health centers: A call to action.
The following applies to health centers or clinics that meet CMS criteria for FQHCs.
Medicare, Qualifying Visits and Payment
Medicare Payments for MNT
In compliance with the statutory requirements of the Affordable Care Act, CMS implemented a Prospective Payment System methodology for FQHCs. Under CMS, FQHCs receive an all-inclusive payment for qualifying visits that covers medical services, supplies, and the overall coordination of the services provided to the patient. The all-inclusive payment is called an "encounter payment." The encounter payment is a single flat-rate payment that is based on an average of the reasonable costs of all FQHCs and applies to all services provided to a patient on the same day, except for a qualifying behavioral health visit, or if a person returns to a health center for a completely different medical issue. There are different rates for new and established patients. CMS updates the FQHC PPS base payment rate annually. Refer to CMS resources for more information about the current base payment rate under Medicare.
MNT = Qualifying Visit in FQHCs Under Medicare
Medicare recognizes individual MNT as a qualifying visit for a health center encounter payment for new and established patients. CMS does not reimburse FQHCs for any group services [i.e., group MNT, Diabetes Self-Management Training (DSMT) or Intensive Behavioral Therapy for Obesity (IBT)]; however, individual IBT and individual DSMT can be provided to Medicare beneficiaries when criteria is met.
The health center is eligible to receive an encounter payment for a new or established patient of the health center if a Medicare beneficiary only receives individual MNT during a health center visit, assuming all requirements are met. If a Medicare beneficiary sees another provider or has another qualifying visit on the same day that the MNT is provided, there is no additional, or separate payment for the MNT. Medicare claims submitted by an FQHC should include the G code for the qualifying visit (G0466 or G0467) and the MNT CPT® code 97802, 97803, or G code G0270 with units.
G0466: Federally qualified health center visit, new patient; a medically-necessary, face-to-face encounter.
G0467: Federally qualified health center visit, new patient; a medically-necessary, face-to-face encounter.
Federally Qualified Health Centers must report detailed Healthcare Common Procedure Coding System (HCPCS) coding on the claim to describe all services that occurred during the encounter. All services provided, including the MNT CPT® codes and units, should be indicated on claims even if there is no separate payment for the MNT because the services are factored into cost reports that determine a health centers' encounter rate in the subsequent year. For more information refer to FAQs on the Medicare FQHC PPS.
Health Centers that meet FQHC criteria are paid for services provided to patients covered by a Medicare Advantage (MA) organization at the rate that is specified in their contract. If the MA contract rate is less than the Medicare PPS rate, Medicare may pay the health center the difference, less any cost sharing amounts owed by the beneficiary. This is referred to as a Medicare Advantage "wrap around" supplemental payment. Refer to the MA organization's billing guidelines for how claims for visits for MNT are submitted.
If a state provides benefits for MNT in its Medicaid program, refer to the state's Medicaid policy for nutrition counseling/MNT to better understand the coverage first, then refer to the state's Medicaid billing guidelines for FQHCs to understand how claims for MNT should be submitted. For example, a state Medicaid program could elect to use other codes for nutrition counseling than the MNT CPT®; codes. Some state Medicaid programs may not credential RDNs or recognize the RDN as a billing provider in health centers, requiring claims for MNT to be submitted by another approved billing provider.
If a state does not include benefits for MNT in the Medicaid program, health centers would not receive any payment for MNT when it is the only service provided on a specific date of service. If MNT is provided as an extension of a primary care visit or other qualifying visit, the health center would receive payment for the qualifying visit. Refer to individual state Medicaid program billing guidelines for FQHCs.
The MNT CPT® codes can be used for purposes other than submitting claims or other billing. When MNT does not qualify the health center for payment in a particular state, the MNT CPT® codes may be used for encounter documentation. Use of the MNT CPT codes can also position a health center to examine the effectiveness, cost, and return on investment of providing MNT in the context of primary care services in the Medicaid population.
Medicaid Managed Care Organizations
Approximately 40 states use managed care organizations (MCOs) to deliver care to populations enrolled in Medicaid. Almost 70% of people with Medicaid are enrolled in MCOs. Money from a state Medicaid program flows to the MCO(s), allowing the MCO greater flexibility to manage payments to the FQHC. If a state Medicaid program offers benefits for MNT, participating MCOs must offer at least the same benefits for MNT.
Payment arrangements between MCOs and health centers vary. MCOs are not required to pay FQHCs the PPS fixed rate, however, MCOs are required to pay the health center "not less" than they would pay non-FQHC providers for the same medical services. Some state Medicaid programs may also provide some supplemental "wraparound" payments to FQHCs in situations where the health centers' costs exceed payments. MCOs and FQHCs may also enter into alternative payment methodology arrangement(s).
Because MCO payments may differ, it is important for the RDN to get clarification on how the health centers are paid by each MCO and determine whether MNT is already factored into those payments. Understanding the payments might inform how patients are scheduled and help the RDN understand ways to add value. Personnel in charge of contracting would be able to provide information about the payment arrangements with the MCOs.
Claims for MNT are submitted according to each MCO's billing guidelines. Even if there is no separate reimbursement for MNT (or any other services), providing the MNT CPT® codes in claims demonstrates that MNT was provided, and in some instances, may have an impact on wraparound payments.
Commercial/private payers are generally a small percentage of the payer mix in most health centers that meet CMS criteria for FQHCs, including those that are HRSA-funded. In some geographic areas HRSA-funded health centers are the only health care organization option available, resulting in a higher percentage of patients with private/commercial insurance.
Payment for MNT provided to a person with commercial/private insurance will be dependent on individual benefits and coverage for MNT for their condition(s) and the network status (in network or out-of-network) of the provider and/or health center.
Registered dietitian nutritionists may need to become credentialed with private payers. Claims are submitted according to private payers' billing policies.
A Rural Health Center (RHC) is a clinic located in a rural area designated as a Health Professional Shortage Area and is intended to increase access to primary care services for persons with Medicare and Medicaid. There are two types of RHCs:
- Provider-Based RHCs: a clinic that is an integral part of a hospital, skilled nursing facility, or home health agency that is participating in Medicare and is used, governed, and supervised with other departments of the facility.
- Independent RHCs: free-standing clinics owned by a provider or a provider entity. They may be owned and/or operated by a larger healthcare system, but do not qualify for, or have not sought provider-based status under Medicare.
Rural Health Centers are reimbursed by an all-inclusive rate (AIR) for medically necessary primary health services and qualified preventive health services furnished by an RHC practitioner. Except for certain provider based RHCs, RHCs are subject to a maximum payment rate per visit. The AIR payment covers MNT and DMST and recognizes both as stand-alone visits qualifying the RHC for payment. RDNs are not recognized as billing providers in RHCs, so claims are submitted using the NPI of a recognized RHC billing provider.
Encounters with more than one RHC practitioner on the same day, regardless of the length or complexity of the visit, count as a single visit.
Exceptions to this occur in three situations:
- When a patient has a qualified mental health visit on the same day.
- When a patient has an illness or injury requiring additional diagnosis or treatment after the first encounter
- When a patient has an Initial Preventive Physical Examination (IPPE)
Medicaid programs are required to recognize RHC services. States may reimburse RHCs under one of two different methodologies, the prospective payment system (PPS) or an alternative payment methodology. Visit the Rural Health Information Hub for more information about how states reimburse RHCs through Medicaid. Medicaid benefits for MNT would inform whether an RHC is eligible for payment under the PPS when only MNT is provided.
If alternative payment models are used, there may be greater flexibility in the delivery of services. Medicaid agencies also may cover additional services that are not normally considered RHC services, such as dental services. You can contact your state Medicaid Office or CMS Regional Office Rural Health Coordinator for information on how Medicaid pays for RHC services in your state.
Payment for MNT provided to a person with commercial/private insurance in an RHC will be dependent on individual benefits and coverage for MNT for their condition(s) and the network status (in network or out-of-network) of the RHC. RDNs may need to become credentialed with private payers. Claims are submitted to payers per payer billing guidelines.
Specific Healthcare Services
Hospital observation services allow medical providers to place a patient in an acute care setting, for a limited period of time, so that the medical team can determine if the patient should be admitted as an inpatient or discharged.
Medicare classifies hospital observation as an outpatient service, which is a benefit under Medicare Part B. Medicare allows for Part B services to be provided while a patient is in observation status as long as those services are deemed as reasonable and necessary, as determined by the hospital and the medical team.
If a physician determines that MNT is reasonable and necessary for a Medicare beneficiary during hospital observation, an RDN could provide MNT if all other requirements are met. If it is not appropriate to provide MNT during hospital observation, or criteria is not met, there may be opportunities for referrals to outpatient nutrition counseling services following discharge.
Medicaid and Private Payers
Medicaid and private payers also consider hospital observation status as an outpatient service; however, payers’ rules about length of time a patient may remain in observation status, and coverage and payment for specific outpatient services, such as MNT, may vary. It will be important to verify patient benefits and refer to payer policies regarding covered services during hospital observation.
Registered dietitian nutritionists may provide MNT and other services as part of home health plan of care. Payment for all home health services (e.g., nursing, nutrition, therapy, home health aides, medical social services) are included in the payments that flow from a payer to the provider of home health services, referred to as a home health agency (HHA). HHAs may employ or hire RDNs as independent contractors RDNs to provide services.
Services provided by an RDN, like other services provided as part of home health services, are not separately billable services when the services are provided in the context of an individual's home health benefit. Payments for home health services are bundled payments that factor in the cost of providing multiple services.
There may be situations where individuals may be eligible to receive MNT in the home (separate from home health services) through an MNT benefit (e.g., Medicare Part B benefit for MNT for DM, CKD or three years after a kidney transplant; for conditions covered through commercial insurance benefits; or Medicaid in some states), and when all other requirements are met.
Home health services, although provided in the home, fall under Medicare Part A. MNT is not a covered benefit under Medicare Part A; however, MNT and other services provided by RDNs are often provided as part of home health services. Medicare Part A pays HHAs a predetermined base payment using the Home Health Prospective Payment System (HH PPS), which provides HHAs with payments for each 60-day episode of care for each beneficiary. The payments are adjusted for the health condition, or clinical characteristics, and the service needs of the beneficiary (i.e., case-mix adjustment). If a beneficiary is still eligible for care after the end of the first episode, a second episode can begin.
There are no limits to the number of episodes a beneficiary, who remains eligible for the home health benefit, can receive. For more information, see Home Health PPS. In addition to the Medicare HH PPS, several states also participate in the CMS Innovation Center Home Health Value Based Purchasing Model. The model will be expanded to additional states in 2022. Refer to the model details for more information about the payment methodology.
RDN documentation of a patient's condition and the progress with nutritional management is very important, as it helps the home health agency demonstrate the care being provided. In some situations, documentation may be used to support positive payment adjustments or medical necessity for a patient to receive additional services. Some RDNs are employed by organizations that provide home health services and others could work as an independent contractor.
Medicare Part B beneficiaries receiving home health services could separately receive MNT for DM, CKD, or 3 years post kidney transplant if MNT is not a part of the home health plan of care. Patients would need to be referred to an RDN Medicare provider by an MD or DO, and all other requirements would need to be met.
Home health services are a mandatory benefit in Medicaid but specific benefits for home health services vary from state to state. There may be limits on types of services, the number of days covered or other utilization controls (including prior approval requirements) for each benefit. Refer to your state's Medicaid program for information on enrollee benefits for home health and how home health agencies are paid by the Medicaid program.
Commercial and private insurance companies also contract with home health agencies to provide home health services. As with Medicare and Medicaid, the payments are bundled, with no separate fee-for-service billing for MNT as part of the home health services benefit. If patients have benefits for MNT (outpatient benefits), it may be possible for RDNs to provide the MNT in the home, apart from home health services.
Skilled nursing facility (SNF), nursing home and convalescent home are all terms used to describe a residential facility that provides 24-hour medical care on site. Skilled nursing is a description of the type of service provided in a SNF, which is high level medical care provided by health professionals and specific skilled nursing services, and for which there is specific criteria. Skilled nursing services can be provided in other environments, including the home. See more specific information about when skilled nursing services may be provided in a nursing home below.
Medicare Part A covers skilled care in a Medicare-certified skilled nursing facility if individuals meet specific criteria. There is no separate payment for MNT when it is provided in the context of skilled nursing services (Part A benefit). Payments flow from CMS to Medicare-approved SNFs using the SNF Prospective Payment System (SNF PPS). CMS uses a payment methodology based on individual patient clinical characteristics and functioning, and the care needed to address the patient.
The methodology, which recognizes several aspects of nutrition-related co-morbidities, is called the Patient Driven Payment Model. Payment for dietary services and nutrition counseling provided by RDNs in SNFs is bundled into the payment to the facility. Registered dietitian nutritionists play an important role in influencing the SNF PPS payments which are adjusted at specific intervals based on patient reassessment. Early, time-sensitive assessment and reassessment influence payment. Registered dietitian nutritionists complete at least one section of the Resident Assessment Instrument (i.e., Minimum Data Set (MDS) 3.0) used to identify patient needs.
Documentation of the presence of specific comorbidities (e.g., physician established diagnoses such as malnutrition, obesity, diabetes, kidney disease), use of extensive services (e.g., parenteral feeding), or the need for mechanically altered diets are some examples of how the RDN may influence payments to support the care provided.
Skilled nursing, rehabilitation services, and long-term care services are covered for Medicaid enrollees when state criteria are met and when provided in Medicaid Certified nursing facilities. Federal requirements specify that dietary services be provided and individualized to the needs of each resident. Refer to individual state Medicaid programs for more information about criteria for services and payments to facilities. There are no separate payments for MNT.
Nursing homes provide permanent custodial assistance. Medicare parts A and B do not cover custodial nursing home care. Some medical services and skilled nursing care services are covered for a limited time when criteria (Medicare Part A) are met, and when provided in nursing homes that are also Medicare Certified SNFs. Payment for the services provided by RDNs come from nursing home revenue as well as from Medicare SNF PPS payments as explained in the section on Skilled Nursing Services. The Resident Assessment Instrument (i.e., Minimum Data Set 3.0) is completed for all residents in nursing homes. RDNs also contribute to the nursing home’s bottom line by providing high quality care, which is an important component of nursing home ratings.
Cardiac rehabilitation (CR) programs as defined by the Centers for Medicare & Medicaid Services are physician supervised, comprehensive programs intended for individuals who meet eligibility criteria. The Centers for Medicare & Medicaid Services requires that CR services be delivered either by an outpatient department of a hospital or in a physician-directed clinic.
- Cardiac rehabilitation programs must include the following components and services:
- Physician prescribed exercise
- Cardiac risk factor modification (Includes: education, counseling, and behavioral intervention aimed at decreasing cardiac risk)
- Psychosocial assessment
- Outcomes assessment
- Individualized treatment plan detailing how components are utilized for each patient
The Centers for Medicare & Medicaid Services recognizes the importance of a multidisciplinary approach (e.g., nutrition education and counseling) to CR, however, it does not identify specific discipline or provider involvement in CR services other than the supervising physician. Registered dietitians nutritionists may be qualified to provide cardiac risk factor modification interventions or other services per individual treatment plans as well as perform other roles (e.g., exercise recommendations or tobacco cessation) depending on the RDN's individual scope of practice and competencies.
Medicare Payments for CR Services
Payment for all CR services flows from CMS to the CR provider, which is either the physician's clinic or hospital outpatient department. The CR provider then pays the practitioners who provide CR services. All CR services delivered by other providers (e.g., RDNs, physical therapists) or practitioners (e.g., exercise physiologist) of the CR program, claims are submitted by the physician supervising CR services. Claims are submitted based on the number of "sessions" provided.
Cardiac rehabilitation program sessions allow a maximum of two 1-hour sessions per day, for up to 36 sessions within a 36-week period.
A session is determined using the minutes from all the cardiac rehabilitation services provided to a beneficiary in one day.
To report one session of cardiac rehabilitation services in a day, the duration of treatment must be at least 31 minutes.
Cardiac rehabilitation services offer an avenue for Medicare beneficiaries to receive nutrition counseling through the cardiac risk factor modification component of the CR services.
Example: If a patient receives 20 minutes of cardiac rehabilitation services (diet counseling as part of behavior modification) in the morning and 35 minutes of cardiac rehabilitation services (physical rehabilitation) in the afternoon of a single day, the hospital or practitioner would report 1 session of cardiac rehabilitation services under 1 unit of the appropriate CPT code for the total duration of 55 minutes of cardiac rehabilitation services on that day.
(Note: A beneficiary may receive up to an additional 36 sessions over an extended period of time, if approved by the Medicare contractor.)
Refer to the Medicare Claims Processing Manual, Chapter 32, Transmittal 140 for more details about criteria, how sessions are determined and how claims are submitted.
Private Insurance and Medicaid
Refer to individual plan benefits and coverage details as well as payer billing policies to understand payments for CR services for patients with Medicaid or private insurance.
Intensive Cardiac Rehabilitation Programs
The Centers for Medicare & Medicaid Services approved ICR Programs are defined as physician supervised programs that provide the same items/services under the same conditions as a CR program, however those services are more rigorous and occur more frequently. Per statute, approved ICR programs must demonstrate through peer-reviewed published research that they accomplished one or more of the following for their patients:
- Positively affected the progression of coronary heart disease.
- Reduced the need for coronary bypass surgery.
- Reduced the need for percutaneous coronary interventions
Additionally, approved ICR programs must also demonstrate that their patients achieve statistically significant improvements in at least five measures:
- Low density lipoprotein
- Body mass index
- Systolic blood pressure
- Diastolic blood pressure
- Need for cholesterol, blood pressure and diabetes medications
Intensive Cardiac Rehabilitation programs have expanded beneficiary qualifying criteria to include stable, chronic heart failure in addition to the criteria for standard CR.
Intensive Cardiac Rehabilitation sessions are limited to a total of 72, one-hour sessions, with up to 6 sessions allowed per day, over a period of up to 18 weeks. The RDN can play an important role in helping patients achieve the specific treatment goals of ICR through individual or group education and counseling. Similar to CR programs, separate claims are not submitted for MNT or any other services provided as part of an ICR program. A beneficiary is allowed a one-time switch from an ICR program to a CR program. If a beneficiary switches from ICR to CR, he/she/they will be limited to the number of sessions remaining in the program.
- To better understand Medicare's ICR Benefit policy: CMS Medicare Benefit Policy Transmittal 256.
- For more information about billing guidelines for ICRS: Medicare Claims Processing Manual Chapter 32, Section 140.
- Refer to private payer and Medicaid programs for information regarding patient coverage for CR or ICR services, qualifying criteria and billing guidelines.
A person of any age who requires either dialysis or transplantation to maintain life may qualify for Medicare coverage. Medicare Part B covers dialysis overseen in a Medicare-approved outpatient dialysis facility. The ESRD benefit for dialysis also includes home dialysis, including peritoneal dialysis.
Medicare regulations for End Stage Renal Disease (ESRD) facilities require a qualified dietitian to provide nutrition assessment, recommendations, counseling, and follow-up as part of the dialysis services. The payments for the nutrition care are factored into bundled payments to the dialysis facility.
End Stage Renal Disease facilities furnishing dialysis treatments in a facility or in a patient's home, regardless of modality, receive payment for up to three hemodialysis treatments per week, unless there is medical justification for more than three weekly treatments. The ESRD Prospective Payment System (PPS) provides dialysis facilities with a bundled payment per treatment, for all dialysis services provided during the treatment sessions. There is no separate claim submitted for MNT.
The ESRD PPS provides a training add-on payment for home and self-dialysis modalities and additional payment for high-cost outliers when there are unusual variations in the type or amount of specific medically necessary care, when applicable. Patients have 20% coinsurance for the cost of each session, which includes equipment, supplies, lab tests and most dialysis medications.
Some dialysis facilities also provide services and programs for CKD patients (non-dialysis) and RDNs could enroll as Medicare providers, reassign their benefits to the facility, and the facility can submit claims under Medicare Part B for MNT.
New Payment Models for ESRD to Expand Treatment Choices: Home Dialysis & More Transplants
As of 2021, the Centers for Medicare & Medicaid Innovation requires many dialysis facilities to participate in an alternative payment model for ESRD care, the ESRD Treatment Choices Model. CMS selected ESRD facilities and Managing Clinicians to participate in the model according to their location in randomly selected geographic areas to account for approximately 30 percent of the ESRD facilities and Managing Clinicians in the 50 States and District of Columbia. To learn more about the model, facts about the payments, and to see the list of geographic areas required to participate, refer to the ESRD Treatment Choices Model.
Payment for the services provided by RDNs are included in the model's payments as they are for the Medicare ESRD PPS payments. Because there is a strong financial incentive to have more patients receive home dialysis and/or be in good health to receive a transplant and have good health outcomes a year post transplant, the model is an excellent opportunity to provide MNT and demonstrate the value of the RDN.
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