Medicare Reimbursement for MNT — Navigating the Maze
By Sharon Palmer, RD
Today’s Dietitian
Vol. 8 No. 2 P. 52

Medicare MNT reimbursement issues can be confusing, but help is available.

Weaving your way through the intricacies of Medicare reimbursement for medical nutrition therapy (MNT) can mystify even the most tenacious dietitian. “It’s confusing working with any government system; it’s the nature of the beast. There is still a learning curve out there,” says Michele Chynoweth, RD, CDE, diabetic nutrition consultant in private practice in Bakersfield, Calif. Chynoweth is an MNT advocate who presented on the topic of Medicare MNT reimbursement at the 2005 American Dietetic Association (ADA) Food & Nutrition Conference & Expo.

“I think understanding the Medicare MNT benefit is quite variable. It is related to the professional pool. The benefit has been in place since 2002, but there are some professionals, such as newly credentialed RDs, who haven’t yet enrolled as providers and others that jumped right in from the beginning,” says Pam Michael, MBA, RD, director of nutrition services coverage team for the ADA. Michael has been involved with Medicare and MNT for the past five years, focusing on ADA member education and outreach.

Not only must dietitians working in MNT track the recent legislative activities involving Medicare reimbursement, they must understand and navigate the current system of reimbursement for MNT services while continuously promoting the benefits of MNT in patient outcome—a tall order for any nutrition professional.

The Battle for MNT Reimbursement
There’s no denying that MNT works and has been proven effective in saving lives, preventing diseases, improving quality of care, and saving millions of dollars in healthcare costs. In 1999, the Institute of Medicine of the National Academy of Sciences’s recommendations that MNT, with physician referral, be a covered benefit under the Medicare program boosted the momentum for MNT reimbursement.1

The 2000 Medicare Part B MNT provision contained benefits only for diabetes and renal disease. The Medicare Modernization Act (MMA), passed by Congress in December 2003, enhanced the MNT benefit in several ways, though it was limited to diabetes and renal disease. Advocates were hoping for more. “With the Medicare Modernization Act, ADA expected the expansion of the MNT benefit, but CMS [Centers for Medicare & Medicaid Services] did not interpret the law the same way,” reports Chynoweth.

The Medicare Medical Nutrition Therapy Act of 2005 (H.R. 1582 and S. 604), a bill that may give the CMS the authority to expand the MNT benefits to include any disease, disorder, or condition deemed medically reasonable and necessary, has been introduced by Rep Fred Upton (R-Mich.) and Sen Larry Craig (R-Idaho). If passed, it would be dietitians’ dream come true.

A Snapshot of Current MNT Benefits
Through all the twists and turns of legislative advocacy that champion MNT benefits for Medicare beneficiaries, the way it stands today is that Medicare Part B covers MNT when it is ordered by a physician for people with kidney disease (who aren’t on dialysis), have a kidney transplant, or have diabetes. These services can be provided by an RD or Medicare-approved nutrition professional and may include nutritional assessment and counseling. Medicare recognizes a nutrition professional as a qualified dietitian, licensed RD, licensed nutritionist that meets the RD requirement, or grandfathered nutritionist who was licensed as of December 12, 2000.

The MMA expanded the number of preventive services and screenings covered effective January 1, 2005. All newly enrolled Medicare beneficiaries are covered for an initial preventative physical examination (IPPE). This is a one-time benefit that must be completed within the first six months after the effective date of the beneficiary’s first Part B coverage. The IPPE, known as the “Welcome to Medicare” exam, consists of seven elements that include education, counseling, and referral based on the results of the review and evaluation. Michael reports that the IPPE is a method of identifying older adults newly diagnosed with diabetes or renal disease who may benefit from a referral to the RD for MNT services. “The IPPE is another track to the Medicare MNT process or an accredited diabetes self-management program,” says Michael.

The expanded Medicare Part B coverage for diabetes includes diabetes self-management training (DSMT) and MNT. “Registered dietitians may be involved with DSMT and MNT. Both have benefits for increasing the quality of care, and they work nicely together,” says Michael, who notes that the DSMT program has its own accreditation process and Medicare enrollment requirements. The doctor must prescribe DSMT, which includes how to manage blood glucose, make informed choices about nutrition and exercise, and prevent and treat complications of diabetes. Medicare will help cover training services in a Medicare-approved diabetes education program, including a total of 10 hours of initial training in 12 months, an additional two hours of follow-up training each subsequent year, and yearly prescriptions from the physician.

In addition, people with diabetes can receive MNT when prescribed by the physician. An RD or a nutrition professional can provide MNT services to include a review of current eating habits, nutrition counseling, managing lifestyle factors, and follow-up visits to monitor progress. Medicare will cover a total of three hours of one-on-one or group services, an additional two hours of follow-up services each subsequent year after the first year of services, yearly prescriptions from the physician, and additional hours of services prescribed by the physician if the condition, treatment, or diagnosis changes.

The Logistics of Reimbursement
Since MNT is a Medicare Part B benefit, an RD or nutrition professional can bill Medicare Part B for providing MNT services. But it is important to comply with all CMS regulations when billing. The CMS defines diabetes as diabetes mellitus type 1 and 2 and includes gestational diabetes. The criterion for a diagnosis of diabetes is a fasting glucose greater than or equal to 126 milligrams per deciliter. The criterion for gestational diabetes is any degree of glucose intolerance with onset or first recognition during pregnancy. Renal disease is defined as chronic renal insufficiency, end-stage renal disease when dialysis is not received, or the medical condition of a beneficiary for 36 months after kidney transplant. Chronic renal insufficiency is defined as the stage of renal disease associated with a reduction in function not severe enough to require dialysis or transplantation.

Dietitians must enroll as Medicare providers and bill Medicare utilizing their own provider identification number. Dietitians may elect to reassign their Medicare reimbursement to the hospital or physician clinic where they are employed and authorize their employer to bill Medicare on their behalf.

Once a Medicare participation agreement has been signed, the participant has agreed to accept assignment for any item or services for which payment is made on a fee-for-service basis by Medicare Part B carriers. Although the charge may be higher than the Medicare approved payment rate, you may only bill and collect the Medicare-approved rate for the MNT service.

To oversee administration of Medicare Part B services at the state level, the CMS establishes contracts with local insurance companies called carriers. The carriers perform provider enrollment, claims processing, audits, and other Medicare activities. Dietitians interested in becoming Medicare providers for MNT should contact their local carrier for a Medicare provider enrollment packet. The carriers contact information is listed on the ADA Web site (see sidebar on page 56).

Groundbreaking Work in Medicare MNT
Emily Cook, vice president of product development for American Healthways, which operates disease management call centers throughout the country, is working on a Medicare Chronic Care Improvement Pilot (CCIP). The CCIP is part of the MMA, which provides for 10 three-year randomized, controlled studies of chronic care management for heart failure and complex diabetes. American Healthways received one of the awards granted by the government for this program in Maryland/Washington, D.C. They are also participants in CIGNA’s Georgia award.

“The legislators were convinced enough of its probable success. They wanted to authorize it to continue if proven successful. It was deemed a pilot. This is a significant departure from typical Medicare demonstration projects,” says Cook. “The focus is to broaden the program to include wellness initiatives to help patients live healthier lives.”

Cook explains that the CCIP is at 100% fee risk for a 5% net decrease spent in claims. There are 20,000 beneficiaries in the intervention group and 10,000 beneficiaries in the control group with heart failure and complex diabetes in each program. “We have to demonstrate in our intervention group that Medicare spent 5% less on their care,” says Cook. American Healthways employs healthcare professionals such as nurses, dietitians, physicians, and social workers to enhance patient care. “We have to pay for these services over and above what we charge to deliver care and show a 5% decline in costs over a three-year period,” reports Cook, who emphasizes that the focus is on keeping beneficiaries well and their symptoms under control. “This is under the theme ‘pay for performance.’ We can be judged by the quality of care we support. In the published literature, there is evidence of clinical outcome improvement with disease management but mixed evidence of financial improvement. The legislation defines success as achieving budget neutrality.”

American Healthways has set up call centers with elaborate computer systems that create a health record for each person. “This record is created before we have contact with beneficiaries. We develop a care plan for beneficiaries with the physician. If we decide that they don’t understand their diet, we may call in the dietitian to have a more in-depth conversation about the diet,” says Cook. “We make internal referrals to dietitians who work the call centers. We love to get the dietitian involved. We use them liberally. We promote MNT and educate beneficiaries how to gain access to it.”

Going Around the System
Toni Kuehneman, MS, RD, LMNT, works in a chronic care improvement program for heart failure at Alegent Health Heart and Vascular Institute in Omaha, Neb. Kuehneman says, “We guide the patients to improve the quality of life. Of all the nutrients the person has to be careful with, sodium is the most important. It is easier to follow a low-fat diet and monitor portions, but there are still so many hidden sources of sodium. The value of the dietitian is sorting out the many puzzle pieces to a low sodium diet.”

Kuehneman’s facility uses a team approach in the heart failure program with a referral to the dietitian as part of the protocol. The MNT protocol includes an initial visit and follow-up visits for assessment and intervention. Some nutrition strategies include teaching self-management skills, patient problem solving, diet recall, nutrition classes, support, and focus groups.

Since Medicare does not reimburse Kuehneman’s services, her role is funded creatively. Originally, one cardiologist wrote a grant to cover nutrition education, but now her salary is paid by the hospital. “Heart failure programs are cost-saving programs, not revenue-generating. I tracked my outcomes and readmissions to show cost-savings value. Heart failure is the most frequent admitting diagnosis for Medicare beneficiaries. If a patient with heart failure is readmitted within 30 days of discharge, Medicare will not reimburse this admission. The hospital assumes the cost. The most frequent reason for these readmissions is noncompliance with medication and/or diet. By providing self-management training and close monitoring, heart failure programs prevent readmissions, thus the cost savings.”

Dietitians can seek funding for disease management programs through grants from hospital foundations or community benefit trusts that provide money to develop programs. By researching data on hospital admissions for heart failure, dietitians can demonstrate that successful programs reduce costs by preventing readmissions. Kuehneman successfully demonstrated the impact of nutrition intervention in a heart failure program. The data was published in a 2002 issue of the Journal of the American Dietetic Association.2 Dietitians can also utilize the cardiac rehab program as a resource for developing a heart failure program without additional staff.

Finding Help
An astonishing array of resources for understanding the latest MNT reimbursement issues is at the dietitian’s fingertips these days. “We try to keep information posted and dated on the Web site. It’s really important for dietitians to keep an eye on this information,” says Michael of the ADA Web site (www.eatright.org), which hosts a large volume of material on MNT and Medicare reimbursement. She suggests that dietitians utilize the MNT link on the ADA Web site and bookmark the RD provider section. “Registered dietitians should keep in touch with the Medicare carrier in their geographic area to be on top of local policy decisions and for training and education,” Michael adds. In addition, she advises members to subscribe to the ADA’s monthly newsletter, The Medicare Provider Newsletter, and join the ADA Reimbursement E-list group. There are numerous educational opportunities offered at state and national meetings as well.

“The CMS Web site has resources, and each state has a representative or cochair at the state level,” adds Chynoweth. Dietitians can also provide quality services to Medicare beneficiaries by using professional tools such as the ADA MNT Evidence-Based Guides for Practice: Type 1 and Type 2 Diabetes Mellitus and Chronic Kidney Disease.

Utilizing the MNT Benefit
According to the Association of Diabetes Educators, DSMT and MNT benefits are alarmingly underutilized by Medicare beneficiaries. Data from the Medicare Quality Improvement Organizations reveals that the root cause of this underutilization is limited awareness and confusion of the benefits and how to order the benefits for a patient.

Chynoweth reports that making the public aware of Medicare benefits is one of the greatest challenges. “Many primary care providers are unaware of the benefits, and these providers do the referring, so we need to continue educating about the coverage” says Chynoweth, who suggests getting involved in older adult advocacy groups and nutrition centers to help educate the public on Medicare MNT benefits.

“In the hospital setting, dietitians can engage in bridging MNT services once the patient is discharged. It is critical for the continuum of care for the newly diagnosed diabetic to be educated on the MNT benefit. MNT is provided over several visits where the RD and individual focus on setting goals to make food and behavior changes. If there’s not an outpatient clinic in the hospital, refer to a RD in the community,” says Michael, who also believes that the private practice setting holds opportunities for marketing the MNT benefit as part of the business plan for dietitians and can impact the RD’s patient mix.

The Diabetes Services Order Form (see reference in sidebar) is designed to be an easy and convenient way for physicians or qualified nonphysician practitioners to refer their Medicare patients with diabetes for DSMT and MNT. The standardized form can be used by any facility or healthcare profession and includes the key referral information required to meet Medicare regulatory requirements. It has been recently expanded to include check-off boxes to describe the type of DSMT training services, the hours of DSMT training requested, and the DSMT content.

Making the Future
To make a difference in the MNT reimbursement scene, Chynoweth urges dietitians to promote the profession at the local level. “Show the value of MNT to clients and physicians, write letters to editors. There’s a lot of public interest.” She also advises participating in local organizations to demonstrate nutritional expertise so people know where to find qualified sources of nutrition therapy. “I think in some of the public surveys, the role of the dietitian has become more visible. It has to continue to do so. There are lots of places to fit the nutrition component in. We can be involved in public policies and become advocates for our clients.”

Michael says, “The consumers have a fair amount of power to influence change. Seniors can ask their physician about a referral to an RD for MNT services. This interest helps drive demand and MNT coverage. Promoting the MNT benefit is an opportunity, once again, to show the value of nutrition services in chronic care and cost-effectiveness.”

The recent legislation (S. 604) has been restructured to give the CMS authority to expand coverage to any disease, disorder, or condition where MNT is cost effective. The MNT benefit could be expanded to cover conditions such as hypertension, dyslipidemia, prediabetes, obesity, or HIV/AIDS if there is evidence that nutrition intervention is effective.

“We have always tried to substantiate why MNT should be expanded and evidence that MNT saves dollars. We continue to keep our mantra for cost effectiveness,” adds Michael, who notes that the ADA doesn’t have deep pockets to research these areas as thoroughly as they deserve. “We are keeping an eye out for any vehicle to add MNT onto. This year [2005], it looks like legislative options are closing down. We will revisit next year [2006] to pursue the expansion of disease.”

Kuehneman says, “Two years ago, Congress passed a bill approving coverage for MNT for cardiovascular disease. However, when the law arrived at CMS, they decided that expanded coverage for MNT was not the intent of Congress. While ADA’s Washington staff and legislative network coordinators presented CMS with letters from Congress indicating that expanded coverage was their intent, CMS disagreed. The expanded coverage would have been effective [in January]. This January [was a] sad reminder of what could have been a new beginning for RDs and their patients and clients.”

— Sharon Palmer, RD, is a freelance writer in southern California.

Resources for Medicare and Medical Nutrition Therapy (MNT)
American Dietetic Association (ADA) Medicare MNT Benefit Provider Guide
www.eatright.org/cps/rde/xchg/SID-5303FFEA-B6DB16E3/ada/hs.xsl/shop_1331_ENU_HTML.htm

ADA MNT Reimbursement and Medicare MNT Resources
www.eatright.org/cps/rde/xchg/SID-5303FFEA-4A20B98C/ada/hs.xsl/nutrition_1943_ENU_HTML.htm

Centers for Medicare & Medicaid Services’ Your Medicare Benefits
www.medicare.gov/publications/pubs/pdf/10116.pdf

Diabetes Services Order Form (Diabetes Self-Management Training and MNT Services)
www.diabeteseducator.org/pdf/DiabetesServicesOrderFormFINAL.pdf

Health and Human Services’ Guide to Medicare’s Preventive Services
www.medicare.gov/publications/pubs/pdf/10110.pdf

National Diabetes Education Program Expanded Medicare Coverage of Diabetes Services
http://ndep.nih.gov/diabetes/EMCDS/emcds1.htm

References
1. National Academy of Sciences, Institute of Medicine. The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population, National Acadamies Press, December 15, 1999. Available at: http://www.nap.edu/catalog/9741.html

2. Kuehneman T, Saulsbury D, Splett P, et al. Demonstrating the impact of nutrition intervention in a heart failure program. J Am Diet Assoc. 2002;102(12):1790-1794.