Coronavirus (COVID-19)

As the impact of COVID-19 unfolds, the Academy of Nutrition and Dietetics is gathering resources for food and nutrition practitioners to address preparedness, patient care and food safety and access.

Professional Resource Hub

COVID-19 PRACTICE TIPS

  • Stay informed and follow recommendations of local and federal agencies.
  • Perform within your individual scope of practice.
  • Request training and document competence in new tasks and services.
  • Use the best available evidence-based guidance and resources.

On March 11, 2020, the World Health Organization declared the coronavirus disease, more commonly known as COVID-19, a pandemic due to the number of individuals and countries affected. As a result, many changes in our daily lives are being recommended in order to minimize the spread of COVID-19, including the ones identified in the President's Coronavirus Guidelines for America.

STAYING INFORMED

It's important for nutrition and dietetics practitioners to stay informed of updates and to reinforce the importance of following the recommendations of local and federal government agencies to their patients and clients.

The Centers for Disease Control and Prevention and other agencies, including the U.S. Food and Drug Administration, continue to monitor the outbreak and have issued guidance for both consumers and healthcare professionals alike. Access to critical medical care and safe, nutritious food are being addressed on many levels. There may be additional factors to consider depending on where you reside or the setting in which your practice.

The Academy supports access to medical nutrition therapy services for all citizens during the current public health emergency and efforts to ensure access to food during the COVID-19 response. Measures are being taken to expand telehealth coverage in accordance with the Coronavirus Preparedness and Response Supplemental Appropriations Act, which was passed by Congress and signed into law by the President on March 6. In addition, the U.S. Department of Health and Human Services is working with many agencies in order to provide ongoing nutrition assistance during the pandemic and has issued guidance for these programs.

The Academy is keeping its members up to date through several communications vehicles. Stay informed as new resources and guidance become available by:

SCOPE OF PRACTICE

During the COVID-19 pandemic, RDNs and NDTRs may be asked to expand duties and services as a credentialed practitioner, including screening, treatment and care of COVID-19 patients, as well as taking temperatures and blood pressure, triage/screening and listening to lung and bowel sounds.

While it can be within a credentialed practitioner's scope to assist with COVID-19 through their organizations and practice settings, each practitioner should ensure the duties being performed are within their individual scope of practice.

For example, some RDNs have been trained in the placement of enteral tubes at the patient's bedside and should be encouraged to assist with these procedures as training and facility policy allows. Other RDNs should assist only if they demonstrate and document competence through on-site facility training by their organizations during the COVID-19 response. RDNs with limited experience in caring for patients in intensive care units or who require enteral or parenteral nutrition should collaborate with the physician and pharmacist to order and monitor these therapies to support safe and quality care.

In these unusual times, RDNs and NDTRs are being asked to contribute to patients in critical care in ways that some practitioners may not have previously in their practice. Be open to contributing and learning new skills, but practitioners should ask for training to ensure they have the demonstrated and documented competence to perform the activity.

RESOURCES

This working list of resources will be expanded over time, so check back often. Academy members also are welcome to make suggestions of other science-based resources our staff RDNs should review and consider.

Critical Care Resources

Diabetes

Enteral/Parenteral Nutrition

Food Security, Food Waste and Hunger

General

Pediatric Nutrition and Health

Preparedness and Response

Standards of Practice/Standards of Professional Performance

  • Journal article: Why Do Practitioners Need to Read the Revised 2017 Scope/Standards Documents? (no login)
  • Standards of Professional Performance (SOPP) for RDNs in Nutrition Care — Standards Indicators are as follows:
    • 2.10 Pursues opportunities (education, training, credentials, certifications) to advance practice in accordance with laws and regulations, and requirements of practice setting
    • 3.1 Contributes to or leads in development and maintenance of programs/services that address needs of the customer or target population(s)
    • 3.1A Aligns program/service development with the mission, vision, principles, values, and service expectations and outputs of the organization/business
    • 3.1B Uses the needs, expectations, and desired outcomes of the customers/populations (eg, patients/clients, families, community, decision makers, administrators, client organization[s]) in program/service development
    • 3.1C Makes decisions and recommendations that reflect stewardship of time, talent, finances, and environment
    • 3.1D Proposes programs and services that are customer-centered, culturally appropriate, and minimize disparities
    • 3.4 Executes programs/services in an organized, collaborative, cost effective, and customer-centered manner
    • 3.4A Collaborates and coordinates with peers, colleagues, stakeholders, and within interprofessional teams

Telehealth and Nutrition Services

COVID-19 Q&A

This Q&A section is intended to provide members with information believed to be current and accurate at the time of posting, and will be refined and updated as new information becomes available. (It is not intended as, nor should be construed as, legal, financial, medical, or consulting advice. RDNs and NDTRs should exercise their professional judgment in connection with this information.)

Ask a Question

Clinical

I have been reading in the news that vitamin C is being used to treat COVID-19 with success. Is there any validity to these stories? Also, can it hurt to take vitamin C supplements? Can you take too much vitamin C?

Although there have been recent news reports of some health care facilities administering high doses of vitamin C intravenously to COVID-19 patients, this form of treatment and other therapeutics are currently being investigated.

The role of vitamin C in the treatment of COVID-19 has not been well studied and there is currently no published research looking at the effect of supplementation of vitamin C on the prevention or treatment of COVID-19.

Some studies in the past have shown that oral vitamin C supplementation may shorten the duration of the common cold or its severity, but the findings have been mixed. There is currently no data to suggest that vitamin C supplements can prevent respiratory infections in the general population, nor are there studies on oral vitamin C supplementation on COVID-19 at this time.

A randomized controlled trial is currently underway in Wuhan China, and it will be evaluating the clinical efficacy and safety of intravenous vitamin C infusions for the treatment of severe COVID-19 pneumonia.

As more information becomes available, agencies in the United States, such as the Centers for Disease Control and Prevention will continue to update the Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19).

Vitamin C, or ascorbic acid, is a water-soluble vitamin found in many fruits and vegetables. The recommended daily allowance, or RDA, of vitamin C in individuals 19 years and older is: 90 mg a day for men; 75 mg a day for women; 85 mg a day for pregnant women; and 120 mg a day for women who are breastfeeding. Individuals who smoke require an extra 35 mg a day above the RDA.

In most situations, it is relatively easy to get the recommended amounts of vitamin C through foods and therefore, supplements are not generally recommended.

The tolerable upper level intake of vitamin C is 2000 mg per day for individuals 19 years and older. According to the National Institutes of Health, vitamin C has low toxicity but high intakes are not recommended. The most common complaints regarding supplementing with vitamin C are diarrhea, nausea, abdominal cramps, and other gastrointestinal irritations.

Answered March 26, 2020


I'm working as dietitian in a hospital right now, am I considered essential? Does it make a difference if I'm doing inpatient or outpatient care? What exactly is an essential job?

The Cybersecurity and Infrastructure Security Agency (CISA) of the U.S. Department of Homeland Security provides guidance that is "intended to support State, Local, and industry partners in identifying the critical infrastructure sectors and the essential workers needed to maintain the services and functions" that Americans depend on during the COVID-19 pandemic. This guidance is not binding but rather serves as a starting point for local and state governments to identify key groups of employees during the pandemic response.

According to the U.S. Food and Drug Administration, critical infrastructure industries, including many FDA-regulated industries such as food, drugs, and medical equipment, "have a special responsibility in these times to continue operations."

There are currently 16 designated "Critical Infrastructure Sectors," many of which employ nutrition and dietetics practitioners.

Answered March 26, 2020


Should clinical RDNs wear a mask? Should we do face-to-face consults?

According to the CDC, healthcare personnel should wear personal protective equipment, or PPE, such as gowns, gloves, eye protection (goggles or face shields, not personal eyeglasses or contacts) and a face mask if an N95 respirator is not available when in prolonged contact with patients who are infected with COVID-19.

To protect healthcare personnel, installing barriers to limit contact with patients and limiting the number of staff providing face-to-face consults is encouraged. If it is possible to care for a patient who is infected without face-to-face consults, then it should be done. To help preserve staff and personal protective equipment, as well as ensure staff and patient safety, the CDC recommends delaying elective ambulatory visits during the COVID-19 pandemic. Telehealth options or reduced face-to-face interactions may be encouraged at some healthcare facilities to help with these measures.

The CDC offers methods for assessing risk exposure for healthcare professionals who work in settings that provide care for patients with confirmed COVID-19 or are being tested for it.

Answered March 24, 2020


Homemade infant formula recipes and claims of formula shortages are popping up all over the internet. This is a true safety concern for our infants. How should RDNs respond?

Currently there are no reported shortages of baby formula. If a local store is low or out, it is most likely due to shopper stockpiling and because stores have not yet adjusted inventory levels to make up for the demand. Individuals looking for formula are urged to check other stores and visit the manufacturer's website to search for store locations. To save time and limit exposure to the public, encourage parents to call and ask about formula availability before visiting stores. When purchasing formula, parents are being advised to purchase no more than a supply of formula that will last 10 days to 2 weeks; although stores may be limiting the amount which can be purchased at one time.

The American Academy of Pediatrics and the U.S. Food and Drug Administration does not recommend making homemade baby formula. Homemade formula can cause harm to infants. It is recommended that infants only be fed breastmilk or iron-fortified infant formula that has been commercially prepared to meet the FDA's nutrient requirements. Even if it's just for a few days, feeding babies homemade formula can put them at risk. It is also recommended that infant formulas be prepared according to the package directions. If parents are considering switching formulas, they should seek the advice of their pediatrician first.

According to the AAP, the following should never be fed to infants:

  • Homemade formula with ingredients like powdered cow's milk, raw milk or sugar; plain cow's milk; or milk substitutes like almond or soy milk. They do not have the correct balance of ingredients for infant nutrition.
  • Imported infant formula. It might have too much or not enough of some ingredients. If it was not stored or shipped correctly, it could be unsafe to use.
  • Watered-down formula. It provides an unbalanced diet and can cause serious growth problems. It provides an unbalanced amount of nutrients and can cause serious growth problems.

For parents struggling to find or afford infant formula, local foodbanks may provide free infant formula. Visit the Feeding America food bank map to find a local food bank.

Additional resources include:

Answered March 24, 2020


I am seeing a lot of information on social media about supplements to prevent or protect against COVID-19. What are the best resources to share to clear up misinformation?

Currently, there are no known cures for COVID-19, though research is underway to develop a vaccine. In its continuing efforts to protect consumers, the U.S. Food and Drug Administration, or FDA, has been monitoring and warning companies that offer fraudulent products which claim to help prevent, diagnose, treat or cure COVID-19.

Untested supplements and other products touted as a prevention or cure to COVID-19 that are not regulated by the FDA may be dangerous and potentially life threatening. The U.S. Federal Trade Commission, or FTC, and FDA have jointly issued warning letters to sellers of unapproved and misbranded products claiming they can treat or prevent the virus. Learn which companies have received warning letters and sign up for consumer alerts.

Avoid this, and other coronavirus-related scams with these tips.

Answered March 24, 2020

Business and Telehealth

Are RDNs and MNT Services included in the Centers for Medicare & Medicaid Services Waiver that allows Medicare Part B services to be provided via telehealth and under much broader conditions, including using communications technologies by patients in their homes?

RDN Medicare providers who provide medical nutrition therapy, or MNT, and other covered services under Medicare Part B are included in the new waiver.

Answered March 26, 2020


Is it true that RDNs may be able to get reimbursed/paid for MNT delivered via telehealth due to the COVID 19 public health emergency?

The Centers for Medicare & Medicaid Services, or CMS, has temporarily expanded coverage for Medicare Part B health care services, including MNT, provided via telehealth. Medicare usually covers services provided via telehealth in rural areas only. Many private payers have also modified their policies related to telehealth delivery and payment. For more information, visit the Academy' s Telehealth Quick Start Guide for RDNs. at www.eatrightpro.org/telehealth.

Answered March 26, 2020


Can telehealth services (MNT) be provided to Medicare Part B beneficiaries using the telephone?

It depends on the payer. Medicare specifically requires audio-video connection for MNT and diabetes self-management training, or DSMT, services. Check with Medicare Advantage (Part C) plans, private payers and your state Medicaid program about the ability to do so.

Answered March 26, 2020


I' m an RDN who provides nutrition care in a hospital inpatient setting. Can I provide such care via telehealth during the current national emergency?

Based on procedures put in place by your hospital to prevent spread of the coronavirus, you may be asked to provide care to inpatients via phone from your hospital or home. You should follow your hospital' s policies and recognize that such care still cannot be billed as a separate service to Medicare Part B because it is not an outpatient service.

Answered March 26, 2020


If our state' s Governor makes an executive order that contradicts what CMS officially says, which order should we follow, in terms of our ability to see patients through telehealth?

An executive order by a governor does not impact Medicare guidelines. An executive order by a governor could, however, impact Medicaid payment policies. We are in the process of researching the various executive orders by governors as well as Medicaid state waivers to better understand what it means for RDNs.

Answered March 26, 2020


If we are working in a Federally Qualified Health Center (FQHC), does the Medicare Part B announcement from CMS also apply to us?

If the FQHC is designated as an urban FQHC the CMS waiver applies, and RDNs can potentially provide telehealth to their patients with the patient being in their home. We anticipate that the 3rd COVID supplemental package will allow all FQHCs and Rural Health Clinics to bill for services delivered via telehealth. We will update this document as policies change.

Answered March 26, 2020


I work for a company that provides home health services. Can I provide my services via telehealth and will my company get paid for these services?

Home health services fall under the Medicare Part A benefit. The CMS waiver that expanded coverage for more services delivered via telehealth was for Medicare Part B services only. We anticipate that the 3rd COVID supplemental package will allow flexibilities for telehealth for home health services, but until that passes and guidance is issued, RDNs are unable to provide home health services via telehealth. While company policies may allow you to do so to prevent spread of the coronavirus, it' s a work-around care delivery option that is independent of payment. We will update as policies change.

Answered March 26, 2020


Can I provide pre-transplant nutrition interventions via telehealth? Most of the patients I work with do not have Medicare prior to transplant.

If the services are provided in the outpatient setting, the facility or RDN can check with each payer regarding payer policies for providing services via telehealth during this national emergency. Payment for the MNT would be dependent on individual patient benefits, coverage details, and payer billing policies.

Answered March 26, 2020


What HIPAA-compliant telehealth platforms are available for use by RDNs in private practice?

There are many options available, either as part of practice management platforms or as stand-alone products. RDNs can view product demos and ask colleagues for recommendations or feedback regarding use of specific products. Members can collaborate using the reimbursement online community and/or DPG listservs. A quick Google search will also yield useful results. RDNs can choose a vendor that provides assurances they will protect electronic protected health information, or ePHI, by signing a HIPAA business associate agreement, or BAA. Read this notification from the Department of Health and Human Services for some examples of technology vendors that offer HIPAA-compliant video communication products that will enter into a HIPAA BAA with a covered entity.

Answered March 26, 2020


I have heard that health care providers can use non-HIPAA complaint communications technologies, for example Skype or Zoom, during the epidemic. What is permitted?

RDN providers may temporarily use non-public-facing communications technologies that do not meet the usual HIPPA standards to see Medicare beneficiaries. The ability to use non-HIPAA compliant communication technologies with patients who have private insurance or Medicaid should be confirmed with those payers. For more information, read the tenth question in FAQs from the Department of Health and Human Services Office of Civil Rights notification of Enforcement Discretion, applying to all HIPAA covered health providers providing telehealth services during the emergency.

Answered March 26, 2020


What consent and privacy notifications need to be provided to patients receiving services via telehealth during the COVID-19 national emergency?

 There are at least three aspects related to consent and privacy:

1) Separate consent to receive services via telehealth
Patients/client consent/agreement to receive services via telehealth is required. Under usual circumstances, written consent must be obtained, and many telehealth platforms have features that enable notification and consent. In the context of COVID-19, verbal consent is acceptable. RDNs should document the date and time of the verbal consent in the patient record.

2) Advising patient of privacy risks with communications technologies that are not HIPAA compliant
If RDNs are using temporarily approved communications technologies that do not meet the usual standards for HIPAA compliance, the RDN must inform the patient of the potential risk and obtain the patient's approval to proceed. Providers are also required to minimize those risks.

"...Effectively immediately, the Health and Human Service Office for Civil Rights will temporarily waive penalties for HIPAA violations against health care providers that serve patients in good faith through everyday non-public-facing communications technologies during the emergency. RDNs may use popular applications that allow for video chats. RDNs should notify patients that these third-party applications potentially introduce privacy risks. It is recommended that all steps be taken to use available encryption and privacy modes when using the following applications..."

3) Notification and receipt/acknowledgement of HIPAA policy
Additional HIPAA privacy restrictions still apply, therefore it is recommended at this time to issue a Notice of Privacy Practices to clients, clearly noting any changes to the notice during the COVID-19 pandemic, and documenting the date of issue and date of patient acknowledgement/acceptance (writing and/or verbally). For more information about practicing and getting paid for telehealth, visit the Academy's telehealth section.

Answered March 26, 2020


What is the Medicare reimbursement rate for MNT provided via telehealth to Medicare Part B beneficiaries?

Medicare pays for MNT provided via telehealth at the same rate as in-person visits. See the Medicare physician fee schedule for more information.

Answered March 26, 2020


Do private payers pay for MNT and other services provided by telehealth at the same rate as in-person services?

Private payers, Medicare Part C (Medicare Advantage), and Medicaid may not pay for telehealth services, including MNT, at the same rate, depending on their policies and state telehealth payment parity laws. For private payers, check with provider services (not member customer service) for each payer for their billing policies and fee schedule. Contact your state Medicaid program for its fee schedule.

Answered March 26, 2020


What CPT codes should be used to submit claims for MNT provided via telehealth?

MNT provided via telehealth is still MNT. The CPT® codes used to submit claims to Medicare (and most private payers and Medicaid) for in-person visits are the same codes used for telehealth: 97802, 97803, 97804, G0270. For more information about CPT® and G codes for RDNs, visit the Payment pages on the Academy' s website.

Answered March 26, 2020


What is different about billing (claim form) when MNT is provided via telehealth?

Medicare: Medicare requires use of Place of Service code 02 for telehealth when billing/coding for telehealth services. No modifiers are required. Hospital outpatient departments billing on the UB-04 form should use Revenue Code 780 (telehealth service).

Private Payers/Medicare Part C (Medicare Advantage)/Medicaid: Each payer determines their own rules. Get clarification individually from private payers and state Medicaid programs for how to submit claims for MNT provided via telehealth. Clarify the following:

  • Place of Service code, if other than 02, and/or
  • Use of any modifiers. For example, modifier 95 describes synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system.

Answered March 26, 2020


Some clients/patients are claiming that they do not have copayments for services provided via telehealth during this time. Does this apply to MNT?

Many private payers are waiving copayments for some, or all health care services delivered via telehealth during the COVID-19 health emergency. Contact private payers regarding policy changes. Check private payer websites for provider information and/or contact provider services representatives if further clarification regarding MNT/nutrition counseling is needed.

Answered March 26, 2020


 I have heard that RDNs can bill using Online Assessment and Management Services codes. Is that correct?

The new online assessment and management services codes are not MNT codes, but provide payment for electronic communications when the communication has been initiated by the patient following an MNT visit. These codes (G2061, G2062 and G2063) became available Jan 2020, are designed for established patients, and are payable under Medicare when requirements for using the codes are met. Check with private payers and your state Medicaid program to confirm adoption of and payment for the equivalent CPT codes (98970, 98971 and 98972). For more in-depth information, read the November 2019 issue of the MNT Provider.

Answered March 26, 2020


Can an accredited DSMT program that is a certified provider under Medicare Part B bill for DSMT (G0108, G0109) when the RDN is working from home or an off-site location?

DSMT (G0108, not G0109) is on the list of Medicare approved telehealth services and falls under the current CMS waiver. So, the DSMT program would be able to submit claims to CMS for DSMT services provided via telehealth to Medicare beneficiaries in their homes.

Answered March 26, 2020


Can I provide weight management services that are required prior to bariatric surgery via telehealth?

Since there is no Medicare benefit for MNT for obesity, the question is addressed in the context of private payers or Medicaid. If RDNs are providing pre-surgical weight loss intervention prior to surgery in the outpatient setting, practices/RDNs can check with payers to see if exceptions have been made to telehealth policies as a result of COVID-19. Separate payment for MNT provided as pre-surgical weight management interventions would be dependent on individual patient benefits, coverage conditions, and payer policies regarding claims submissions.

Answered March 26, 2020

Does professional liability insurance cover services provided by telehealth?

Many professional liability insurance policies offer coverage regardless how the service is delivered. At its core, a professional liability policy is written to cover an RDN for allegations of failure to provide professional services. In general, telehealth is considered to be part of the definition of professional services and may therefore already be covered under an existing policy, unless specifically excluded under the terms of the policy. Because all insurance companies and policies are different, RDNs should check with their insurance provider to be sure their professional liability insurance covers telehealth services and inquire whether an added endorsement is needed to their policy for telehealth services. Additionally, RDNs should not assume professional liability coverage for telehealth delivered services is viable across state lines. (Keep in mind, RDNs must be licensed in the state(s) in which the patient is receiving services, where licensure is applicable, whether the service is provided face to face or via telehealth.) RDNs should also inquire if the policy extends to services provided outside of the RDN' s resident state. As telehealth adoption increases, new policies may be adopted. RDNs should review their liability coverage details annually. The professional liability insurance offered through the Academy's Member Advantage Program (Proliability administered by Mercer Consumer) does not exclude telehealth/telemedicine services.

Answered March 26, 2020


In the context of the inpatient setting, I have been restricted from going to the patient floors and have been told by my CNM that I can only do nutrition assessments on the telephone. Is this within my licensure to do telephone assessments?

In general, practitioners should look at their state licensure laws and regulations (some states may, for example, require that initial nutrition assessments or visits be face to face), as well as any notifications about requirements that may be temporarily suspended to accommodate service delivery during the pandemic response. If in doubt, reaching out to your state health department is recommended.

Answered March 25, 2020


I am an RDN who usually provides in-person counseling. Do you have any advice for those of us who must suddenly switch to telehealth?

The Academy has a quick guide and tip sheet available for members and provides guidance about practicing telehealth during the COVID-19 national public health emergency. The guide is for RDNs who are not working in facilities and who already provide in-person MNT to consumers with Medicare, commercial/private insurance, and/or Medicaid (e.g., already a network provider with payers).

Answered March 24, 2020

Food Security and Access

What recommendations are there for food delivery shipments at hospitals and long-term care facilities to help decrease the risk of COVID-19 transmission from vendors? Are there any recommendations for food service staff in these types of facilities to help reduce the spread of COVID-19?

There is currently no evidence to show food or food packaging as a means of transmission for COVID-19. It may be possible for viruses to survive on surfaces and objects, though, reinforcing the need to observe proper hygiene and food safety practices.

Hospitals and other facilities may limit access vendors and third parties have to their buildings during the current COVID-19 outbreak. Food suppliers that previously were able to deliver food indoors may be required to leave packages outside, and staff may be required to bring them inside to align with physical distancing measures. The Academy's Dietetic Practice Group, Dietetics in Health Care Communities, recently recorded a webinar on Front and Back of House Precautions for nutrition and dietetics practitioners working in these settings. Local and state health departments also may have guidelines established during this pandemic and should be consulted.

Regular handwashing, along with routine cleaning and disinfecting, especially all frequently touched surfaces, remain the most effective ways to reduce the spread of COVID-19 and are essential in any food service setting. Additional information regarding Food Safety and the Coronavirus Disease 2019 (COVID-19) is available on the U.S. Food and Drug Administration's website.

Answered March 26, 2020


I've noticed grocery stores running low on items, does this mean there is a food shortage?

According to the USDA, there are currently no food shortages. If grocery shelves are low in certain food items or supplies this is an issue with inventory or how much the store ordered based on what it expected to sell. A recent and unexpected increase in demand for groceries and non-food items has left many stores with little time to restock shelves.

FEMA is asking individuals to only buy enough groceries for one week. The United States Department of Agriculture and the U.S. Food and Drug Administration are closely monitoring the food supply chain for any shortages.

Answered March 24, 2020