Medicare MNT Benefit, Practice Setting Considerations
Q: Can RDNs provide the Medicare MNT benefit in any practice settings, besides the traditional outpatient nutrition clinic or private practice?
A: Medicare Part B MNT can be provided in many settings, yet not all. Several points to consider as you determine whether the MNT benefit can be applied to various RDN practice settings including the following.
Review regulations and original "source" documents.
For any question about the Medicare Part B MNT benefit, including practice settings where the MNT benefit applies, review the original "source" documents determined by Congress or the Centers for Medicare & Medicaid Services (CMS). The Medicare Part B MNT benefit final regulations1 indicates "Medicare will pay dietitians who enroll to obtain provider status in the Medicare program regardless of whether they provide the MNT services in an independent practice setting, hospital outpatient department or any other setting, except for services provided to patients in an inpatient stay in a hospital or skilled nursing facility." Effective January 1, 2006, CMS determined MNT can be provided to qualifying Medicare Part B beneficiaries in Federally Qualified Health Centers (FQHC). However, separately billable MNT under Medicare Part B is not allowed in Rural Health Centers.
If nutrition services are bundled into other hospital/clinic/facility services that are billed to Medicare, then you are not able to bill Medicare Part B for the MNT benefit for diabetes and non-dialysis kidney disease.
For example, food and nutrition services, including assessment of nutritional status, diet instructions and counseling provided by RDNs, for hospitalized patients (in-patients) are bundled (included in) into room and board fees under the hospital Medicare Part A "conditions of participation2." The Medicare Part B MNT benefit is not available to hospitalized Medicare patients (inpatients) since nutrition is bundled into hospital charges and billed under Medicare Part A.
Example 2: An RDN is providing MNT to a patient receiving dialysis for kidney failure and who now requires additional nutrition intervention for diabetes. The patient is receiving services at the outpatient, end stage renal disease (ESRD) facility. Medicare regulations for ESRD facilities specifically require a qualified dietitian to provide nutrition assessment, diet recommendation, patient counseling and follow-up services to monitor diet adherence3. In this case, the RDN's MNT services are not reimbursed as a separate charge, but are bundled in with all services provided to the dialysis patient at the ESRD clinic. As a result of the patient's change in medical condition, the RDN modifies the previous diet, and counsels the patient on a food plan for both dialysis and diabetes. The RDN's nutrition consultation is provided as part of all of the services provided under the Medicare Part A ESRD program. In this case, since the ESRD program includes nutrition services, the RDN cannot unbundle and cannot separately bill his/her services for the diet modifications for diabetes nutrition counseling.
Review contracts or employment relationships established between the RDN and facility or healthcare professionals (e.g., MD); the contract may impact whether the RDN is able to provide MNT under the Medicare Part B benefit for diabetes and non-dialysis kidney disease.
For example, an RDN wants to work for a physician and provide MNT to the physician's Medicare Part B qualifying patients. Now that RDNs are Medicare providers who can bill Medicare Part B directly, consider how this will impact your working relationship with the physician or clinic. Who will submit claims for the RDN services? The RDN, or will the RDN work out an arrangement with the physician where the clinic office staff will submit claims on behalf of the RDN? If the clinic bills for the RDN, the RDN will reassign her/his Medicare benefits to the physician/clinic, and payment will be sent to the physician's office. (Remember: Medicare MNT for diabetes and non-dialysis kidney disease cannot be billed 'incident to' physician services.)
Example 2: An RDN is a consultant at a home health agency and he/she is interested in providing MNT to Medicare Part B beneficiaries with diabetes or non-dialysis kidney disease. The RDN should review his/her contract with the agency to determine how it defines the RDN's services. In many cases the RDN may be employed and provide consultative services that include nutrition assessment and recommendations. This is most likely provided through the Medicare Part A home health benefit which bundles nutrition services among the other services provided by the home health agency. The RDN involvement may be as limited as interacting with nursing staff to suggest intervention steps for the patient, or the agency could utilize the RDN to provide direct consultation to the patient.
However, in this scenario, the RDN might want to pursue setting up another contract where the RDN could expand his/her services with the agency by making home visits and providing MNT (assessment, intervention, and follow-up intervention) to qualifying Medicare Part B beneficiaries with diabetes and non-dialysis kidney disease. The RDN, as a Medicare provider, would submit the claim directly to the local Medicare carrier, or depending on provisions in the contract, could reassign the benefit to the home health agency.
The Medicare Part B MNT benefit for diabetes and non-dialysis kidney disease may provide RDNs employed in home health agencies with the opportunity to expand their services. The agency can benefit from the RDN's MNT services as MNT can improve the patient’s overall health and adherence to other medical regimens/education therapies. If the RDN establishes a new contract, he/she will also need to set up a system to assure the benefit regulations are followed, for example, prior to visiting the patient in their home, the RDN needs to make sure a physician's referral is obtained, and the RDN should verify the Medicare patient qualifies for the benefit. Remember, expenses — e.g., vehicle or gas costs — to provide Medicare Part B MNT in the home to qualifying beneficiaries are not reimbursable by Medicare.
1. Federal Register, 42 CFR, Part 405 et al, Vol 66, No. 212, November 1, 2001; Medicare Program; Revisions to Payment Policies and Five-Year Review of and Adjustments to the Relative Values Units Under the Physician Fee Schedule for Calendar Year 2002: Final Rule.
2. Medicare Intermediary Manual -Pub.13; and Federal Register 42 CFR,§482.28.
3. Federal Register, 42 CFR §405.2102.
*The information is for reference use only and does not constitute the rendering of legal, financial, or other professional advice of the Academy of Nutrition and Dietetics. (10/06)