Prior to initiating nutrition services such as medical nutrition therapy (MNT) services, RDNs should consider whether a referral is necessary or appropriate. A variety of factors impact referrals including payer policies that may be providing direct reimbursement to the RD, the extent to which state licensure laws may define the need for a referral, facility policies such as those addressing quality clinical care and continuity, and the type of service being provided by the RDN. [For more details, see the August 2008 Journal of the American Dietetic Association (now Journal of the Academy of Nutrition and Dietetics) article, "Referral Systems in Ambulatory Care — Providing Access to the Nutrition Care Process."]
For example, the federal government, under Medicare Part B, requires a physician (MD/DO) referral for Medicare Part B coverage of medical nutrition therapy (MNT) services for diabetes and non-dialysis kidney disease provided by RDN Medicare providers. There are instances in which private sector payers do not require a referral, as in the case of many disease management programs where MNT or nutrition services are included as part of the disease management program. In many of these cases, patients/clients qualify for the service based on their existing health condition, such as diabetes or obesity, which allow the patients/clients direct access to MNT services without the need for a physician referral.
Currently, only a handful of the 46 state laws that regulate dietitians or nutritionists through licensure, statutory certification or registration explicitly require a referral or physician order. Still, RDNs should not assume that their state does not have such a requirement. Even in explicit cases, the referral language may differ in each state's legislation. Nutrition licensure laws and information are posted on the Academy's State Affairs Web page.
Tip: Because nutrition licensure laws are often lengthy documents and MNT referral-related language may appear in various sections of the text, RDNs can save time by searching for "referral" using a computer's "find" function.
Requirement: Physician or "a Health Care Provider" Referral Requirements
Description: Several states licensure statutes describe that a physician or a health care provider authorized to prescribe dietary treatments initiate a referral for nutrition services. It will be noted, therefore, that the referral of a qualified health care provider, such as a physician, is apparently an essential antecedent to the RDN's ability to practice dietetics or nutritional services of any kind. The statutes of some other states also contain references to a physician's participation or supervision in the nutrition care process, but they are not nearly as restrictive as Alabama and California.
"[A] dietitian/nutritionist or registered dietitian … may [provide such dietetic services as nutritional assessments and nutrition counseling] upon referral by a health care provider authorized to prescribe dietary treatments", and "[d]ietitians/nutritionists may offer advice and counsel on dietetics and nutrition as adjunct medical therapy when advice and counsel is given upon referral of a licensed physician." Ala. Code 1975 §§ 34-34-2 and 34-34A-5 (emphasis added). ["Adjunct medical therapy" is not otherwise defined.]
"[A] registered dietitian, or other nutritional professional meeting the qualifications [of this statute] may, upon referral by a health care provider authorized to prescribe dietary treatments, provide nutritional and dietary counseling, conduct nutritional and dietary assessments, and develop nutritional and dietary treatments, including therapeutic diets, for individuals or groups of patients in licensed institutional facilities or in private office settings." Cal. Bus. & Prof. Code, § 2586 (emphasis added).
A licensed dietitian or nutritionist may generally engage in the practice of dietetics, but may not develop a "therapeutic dietary regimen" unless it is "pursuant to the appropriate orders and/or referral of licensed practitioners of medicine, osteopathy, chiropractic, dentistry, or podiatry when incidental to the practice of their respective professions." Tenn. Code Anno., §63-25-105. [Unfortunately, the term "therapeutic dietary regimen" is not defined or otherwise referenced in the statute.]
Requirement: Statutory Provisions Designed to Address Conduct When Physicians are Already Involved.
Description: Certain states, while not requiring referrals in all cases, have included statutory provisions designed to address conduct when physicians are already involved.
"[A] licensee under this part shall not implement a dietary plan for a condition for which the patient is under the active care of a [licensed] physician … without the oral or written dietary order of the referring physician," except that "[i]n the event the licensee is unable to obtain authorization or consultation after a good faith effort to obtain it from the physician, the licensee may use professional discretion in providing nutrition services until authorization or consultation is obtained from the physician." West's F.S.A, § 468.516(1)(a).
When a referral relationship exists, licensees shall provide ongoing communication with the licensed physician practitioner regarding changes in plans of care, treatment programs, and termination of services. Licensees shall take reasonable action to inform a client's physician and any appropriate allied health care provider in cases where a client's nutritional status indicates a change in medical status. Code of Mass. Regulations, 268 CMR §5.03(3).
Requirement: Physician Involvement When the Treatment or the Condition Being Treated Becomes Medical in Nature
Description: Some states mandate the involvement of a physician when the treatment or the condition being treated becomes what the state defines as medical in nature.
"Medically prescribed diet" means a diet prescribed when specific food or nutrient levels need to be monitored, altered, or both as a component of a treatment program for an individual whose health status is impaired or at risk due to disease, injury, or surgery and may only be performed as initiated by or in consultation with a physician licensed to practice medicine in all its branches. [225 ILCS 30/10.]
In excepting persons providing weight control services from dietetic licensure, nevertheless requires that the weight control program either recommend physician consultation or require physician referral when certain medical conditions exist. Maine Revised Statutes Anno., 104 M.R.S.A. § 9915(5).
"Nutrition care services" will include, among a number of other things, "implementing a physician's written and verbal orders which pertain to the practice of dietetics, if the practice of dietetics is specifically authorized by the medical director and the health care facility where the care is taking place. In the delivery of dietetic home care, this care must be authorized specifically by the physician sponsor…." Code of Laws of South Carolina Anno., Sec. 40-20-20.
Requirement: Dietitian's Activities Based on Physician's Order
Description: Some of the other state statutes, while not requiring the participation or involvement of a physician in most aspects of the dietetics practice, specifically permit or require the dietitians to transcribe or act upon the physician's orders.
Section 20-206q of Chapter 384b, reads as follows: Section 20-206q. Verbal orders from physicians. When a physician conveys an order for a diet or means of nutritional support to a certified dietitian-nutritionist by verbal means for a patient in an institution …, such order shall be received and immediately committed to writing in the patient's chart by the certified dietitian-nutritionist. Any order so written may be acted upon by the institution's nurses and physician assistants with the same authority as if the order were received directly from the physician. Any order conveyed in this manner shall be countersigned by the physician within twenty-four hours unless otherwise provided by state or federal law or regulation.