Avoiding Denials in Nutrition Therapy: Correct CPT & HCPCS Code Usage

Are your nutrition therapy claims being denied more often than they should?

Do you know which CPT and HCPCS codes to use for Medical Nutrition Therapy (MNT) to ensure maximum reimbursement?

Many practices struggle with claim denials simply due to incorrect coding, missing referrals, or incomplete documentation.

Could a simple misstep in selecting a code or recording session time be costing your practice hundreds, or even thousands, in lost revenue each year?

In a rapidly growing healthcare scenario where diabetes, kidney disease, and other chronic conditions are on the rise, understanding the correct use of MNT codes is more important than ever.

This blog will provide a step-by-step guide on correctly using CPT and HCPCS codes for Medical Nutrition Therapy to avoid denials.

Step 1: Select the Correct Code

Accurate billing for MNT begins with choosing the right CPT or HCPCS code. The choice of code depends on whether the session is an initial assessment, a follow-up visit or a reassessment prompted by a change in the patient's condition.

CPT Codes for MNT

• 97802 is used for the initial individual assessment and intervention. Each unit represents 15 minutes. This code applies only to the patient’s first session.
• 97803 applies to subsequent individual follow-up sessions and is also billed in 15-minute increments. It ensures continuity of care for ongoing nutrition therapy.
• 97804 is for group sessions with two or more patients and is billed in 30-minute units. This code covers both initial and follow-up group sessions.

HCPCS Codes for Special Situations

• G0270 is used for individual reassessments and interventions when a patient receives a second referral in the same year due to a change in diagnosis, condition, or treatment plan. Each unit represents 15 minutes.
• G0271 applies to group reassessments under similar circumstances and is billed in 30-minute units.

Pro Tip: Use CPT Codes for standard initial and follow-up sessions. In fact, switch to G-codes only when there is a documented change in the patient's condition or a new referral is received. Proper code selection is the first step in avoiding denials and ensuring compliance.

Step 2: Calculate Units Correctly

The accuracy of the billing requires calculating units that reflect the actual time spent with each patient. Each CPT or HCPCS code corresponds to a specific time increment, and reporting the correct number of units is essential for proper reimbursement.

Unit Breakdown for Individual and Group Sessions

• 97802 / 97803 (Individual sessions): One unit equals 15 minutes. For example, a 45-minute initial session is billed as three units of 97802.
• 97804 / G0271 (Group sessions): One unit equals 30 minutes. A two-hour group session would be billed as four units of 97804.

Step 3: Use Nutritionist’s Credentials (Not Incident-To)

Medical Nutrition Therapy codes are specific to Registered Dietitians (RDs) or other qualified nutrition professionals. These services should never be billed as "incident-to" to a physician, as this is a common reason for claim denials.

• Use the Nutritionist’s NPI/PIN

When submitting claims for MNT services, always use the nutritionist’s unique National Provider Identifier (NPI) or Provider Identification Number (PIN). Billing under the physician’s NPI can lead to denied claims and may trigger audits from payers.

• Avoid “Incident-To” Billing

“Incident-to” billing applies only when a non-physician provides services under direct physician supervision in specific circumstances. As MNT codes are nutritionist-specific, reporting them as incident-to a physician is incorrect and can result in payment rejection.

Step 4: Verify Payer-Specific Rules

Coverage for Medical Nutrition Therapy varies across Medicare, Medicaid and private insurance plans. It is essential to verify each payer's rules before providing services to prevent claim denials and unexpected out-of-pocket costs for patients.

• Medicare Coverage

Medicare provides coverage for patients with diabetes, renal disease, or those who have had a kidney transplant within the last three years. In the first year, beneficiaries may receive up to three hours of MNT while subsequent years allow for two hours. In fact, additional sessions are reimbursed only if there is a documented change in the patient's condition or treatment plan, billed using G0270 or G0271 codes. Further, copayments, coinsurance and deductibles are waived for qualifying patients to ensure complete coverage for necessary services.

• Private Insurance Coverage

The coverage policies for private insurers differ significantly. Though some plans provide a fixed annual dollar amount for MNT services, others reimburse only for specific diagnoses. Many plans require a physician referral and documentation of medical necessity. In fact, obtaining written confirmation of each payer’s coverage policy is a best practice to avoid claim denials and unexpected patient charges.

Step 5: Documentation

Proper documentation is crucial for supporting claims, demonstrating medical necessity, and complying with payer requirements.

• Diagnosis Documentation

It is crucial to ensure that the ICD-10 code accurately reflects the patient’s condition and is recognized by the payer. For instance, E11.9 is used for diabetes. Proper diagnosis coding helps prevent claim denials and supports the medical necessity of the service.

• Referral Documentation

A physician referral is required for all MNT services. Health Maintenance Organizations (HMOs) may require a referral certificate number, while Preferred Provider Organizations (PPOs) usually accept a standard physician referral. Always retain a copy of the referral in the patient’s record to support claims and audits.

• Time Documentation

Always record the start and end times of each session in the patient’s chart. This documentation supports the units billed and provides evidence in case of payer audits. Accurate time tracking ensures that reimbursement matches the services delivered and helps prevent denials.

Step 6: Use Proper Billing Forms & Site-Specific Rules

Accurate billing forms and a thorough understanding of the care setting's requirements are essential for proper reimbursement.

• CMS-1500 Form

Use the CMS-1500 form to report MNT services. In fact, each CPT or HCPCS code should be entered on a separate line with the correct units, session duration, and the associated ICD-10 diagnosis code.

• Federally Qualified Health Centers (FQHCs)

In FQHCs, individual MNT visits count as qualifying encounters for payment. Even if separate reimbursement is not allowed, reporting CPT/HCPCS codes is necessary for documentation and compliance purposes.

• Rural Health Clinics (RHCs)

In RHCs, MNT services are generally bundled into the all-inclusive visit rate. Proper documentation of codes is still required, even if separate reimbursement is not provided. It is essential to ensure that accurate reporting supports compliance and future audits.

Step 7: Monitor Denials and Adjust

Even when coding and documentation are correct, claim denials may still occur. Monitoring claims allows practices to identify errors, address issues promptly and improve overall reimbursement.

• Common Denial Reasons

Denials frequently occur due to incorrect CPT or HCPCS codes, missing referrals, mismatched units, wrong use of provider IDs or submission for non-covered diagnoses.

• Denial Management

Each denied claim should be carefully reviewed and reconsidered. In fact, additional documentation can be provided when required and corrected claims should be resubmitted. Thereby, implementing a structured denial management process helps increase reimbursement rates and prevents recurring errors.

• Regular Audits

Conducting periodic audits of MNT claims enables practices to identify trends, address recurring issues and ensure compliance with payer requirements. Regular audits improve overall revenue cycle management and reduce the likelihood of future denials.

Conclusion

Obtaining the correct reimbursement for MNT relies on accurate coding, clear documentation and adherence to payer rules. In fact, choosing the correct CPT or HCPCS codes, accurately recording session time, and utilizing the nutritionist's credentials are key steps to avoid claim denials.

But following these best practices doesn’t always guarantee 100% success as handling MNT billing can sometimes feel complicated, especially with different insurance plans and coverage rules. 24/7 Medical Billing Services helps practices manage this process efficiently. Their team reviews claims, checks for errors, ensures proper code usage, and helps prevent denials so that nutrition services are paid correctly.

FAQs

Q1. Can telehealth MNT sessions be billed using CPT/HCPCS codes?

Many payers allow telehealth MNT using the same CPT/HCPCS codes, but confirm payer-specific telehealth rules.

Q2. Can dietitians bill for MNT without a physician referral?

Most payers require a physician referral, though some private plans allow self-referral for wellness or preventive programs.

Q3. How often can a patient receive MNT in a year?

The frequency limits depend on payer policy, as some allow multiple sessions per year, while others restrict them based on diagnosis.

Q4. Are MNT services reimbursed differently in hospitals vs. outpatient clinics?

Reimbursement rules and billing forms may differ depending on the care setting and payer type.