Places of Service and Specific Health Care 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

There are many settings where MNT could be provided that potentially qualify as an approved place of service (POS) for reimbursement purposes. POS codes are two-digit codes placed on health care professional claims that indicate where a service was provided. Provider agreements and payer policies ultimately determine approved places of service. In addition to the specific places of services identified below, some additional examples of settings that may qualify as acceptable settings include senior center, community-based organization, assisted living facility, patient’s home, and walk-in retail. It is important to seek clarification from each payer regarding the ability to provide MNT in specific settings, and seek clarification regarding correct use of POS codes.

The following sections include information about how payment for MNT occurs in these specific places of service:

  • Office
  • Federally Qualified Health Centers
  • Rural Health Center
  • Hospital-based Outpatient Departments
  • Critical Access Hospital

Specific Health Care Services

The following includes information about how health insurance payments are structured for specific health care services in which RDNs may be providing services. While some of the items refer to specific places, the place of service is not the primary determinant of how the payments work. Each is unique.

  • Hospital Observation Services
  • Home Health
  • Skilled Nursing Care and Nursing Home
  • Cardiac Rehabilitation and Intensive Cardiac Rehabilitation
  • End State Renal Disease Services
  • Office

    There are several settings that may be considered office, including private practice offices of dietitians, primary care and specialist physicians, and other providers.

  • Federally Qualified Health Centers

    FQHCs are health centers or clinics that qualify for funding under Section 330 of the Public Health Services Act and meet specific CMS criteria.

  • Rural Health Centers

    An 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.

  • Hospital Observation 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.

  • Skilled Nursing and Nursing Homes

    Skilled nursing facility, nursing home and convalescent home are all terms used to describe a residential facility that provides 24-hour medical care on site.

  • ESRD Services (Outpatient Dialysis)

    Medicare regulations for ESRD facilities require a qualified dietitian to provide nutrition assessment, recommendations, counseling and follow-up as part of the dialysis services.