For dietitians, accepting insurance can be an effective and dependable way to grow a nutrition private practice. After considering whether to accept insurance in your practice or not, the next question that quickly comes to mind is — which insurance plans should I accept? Medicare is one of the most widely accepted insurance plans, with some of the highest reimbursement rates for dietitians, compared to private payers.
Furthermore, the billing stipulations and regulations set forth by the Centers for Medicare & Medicaid are often regarded as standards — with many private payers adopting Medicare regulations in their own contracts. Understanding the ins and outs of Medicare billing will not only allow you to easily bill Medicare for nutrition services, but will give you great insights into billing requirements across insurance payers.
In this article, we cover the basics of becoming an in-network Medicare provider for nutrition and wellness services including:
- Initial steps to credentialing your nutrition practice with Medicare
- Important basics of billing Medicare for medical nutrition therapy (MNT) services
- How to bill Medicare for telehealth nutrition services
- Medicare billing FAQs
What Type of Nutrition Services Can Be Billed to Medicare?
When deciding whether credentialing with Medicare is the right fit for your wellness practice, it’s important to consider which types of nutrition services can be billed to Medicare. This also helps you understand the patient population that you’ll work with, and whether this is inline with your practice focus.
Medicare is a health insurance program for:
- People age 65 or older.
- People under age 65 with certain disabilities.
- People of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant)
For medical nutrition therapy services in a private practice sector, Medicare will only reimburse dietitians for patients with a diagnosis of:
- Diabetes (Type 1 and Type 2)
- Renal disease
- Recent kidney transplant within 36 months
Medicare will not pay for eating disorder counseling, weight loss counseling, or other MNT services at this time.
Dietitians who are in-network only may bill Medicare for these services, and there are no out-of-network benefits provided. The purpose of this is to encourage Medicare beneficiaries to use their benefits, and seek out wellness professionals who are in-network with Medicare.
Additionally, Medicare has different parts that help cover specific services – Medicare Parts A, B, and D. Dietitians in private practice or outpatient roles will be established with Medicare Part B (Medical Insurance). Part B helps cover doctors’ services and outpatient care. It also covers some other medical services that Part A doesn’t cover, such as some of the services of physical and occupational therapists, and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary. Most people pay a monthly premium for Part B.
How to Become In-Network with Medicare
When you’re ready to move forward and credential your wellness practice with Medicare, the process can be managed online. Here’s the steps you’ll need to take to get started:
1. Create a CAQH profile and give Medicare Access
All insurance payers will need access to your CAQH profile to verify your information, so be sure to set your permissions to allow Medicare to view your profile. This is free to do, but will take approximately 2 hours if you have all of the required information on-hand. Be sure to keep this information on hand, as you’ll likely need some of it for the next step, such as copies of your credentials, and detailed work history information.
Pro Tip: Most providers have an individual NPI number which they include in their CAQH profile and insurance applications. If you have your business set up as an LLC, or have intentions of expanding your practice in the future, you may want to consider obtaining a second NPI for your business. This allows dietitians to credential their practices with Medicare (and other insurance payers) under their secondary/group NPI number and add themselves as an individual within the practice — ultimately allowing for other providers to become credentialed under their business umbrella in the future.
However, if you choose, you can certainly credential and bill under your individual NPI number.
2. Visit the PECOS website and complete the Medicare Provider Application
The quickest way to get your application processed is by submitting it online through the Medicare Provider Enrollment, Chain, and Ownership System (PECOS). PECOS supports the Medicare Provider and Supplier enrollment process by allowing registered users to securely and electronically submit and manage Medicare enrollment information. You will not be able to mail any forms into PECOS with a signature, so expect to e-sign your PECOS documents.
Submitting a Medicare application for dietitians through PECOS is FREE. While there is a fee listed on their website, it does not currently apply to dietitians. If you are prompted to pay for a fee, call CMS directly to clear up the misunderstanding. The application process should also take about 1-2 hours to complete.
3. Follow-up with Medicare to complete the credentialing process
To complete the application, you’ll need to sign the attestation form. Check your email, the confirmation should be there with the link to e-sign your document. Once you’ve e-signed, be sure to submit your application. Your application will not be reviewed until all certifications and documents are received. As Medicare has transitioned their credentialing process online, processing times can be quite quick. You’ll typically hear back from Medicare within 6 weeks, although it could be several months.
Billing Medicare for MNT Services
Once you’ve received a dated contract, you can begin to see Medicare patients (who meet the criteria for nutrition counseling). As mentioned earlier, you will only receive reimbursement for clients that have a diagnosis of:
- Diabetes (not pre-diabetes)
- Renal disease
- Kidney transplant within past 36 months
Diagnosis codes are received from your client’s medical doctor. As dietitians are not allowed to diagnose clients, it’s recommended to received a copy of your client’s latest chart note or a written referral from their MD listing the diagnosis codes. Storing this information securely within your client’s chart notes is essential, and are critical in the event that your practice is ever audited.
The corresponding diagnosis claims must be included in your CMS 1500 claim, along with a Common Procedural Terminology (CPT) code. CPT codes generally used for MNT services include:
- 97802 – For an initial assessment, face-to-face, 15 minutes per unit
- 97803 – For a follow up visit or reassessment, face-to-face, 15 minutes per unit
When creating a CMS 1500 form, you will also have to specify the number of units and your fee per unit. CPT codes 97802 and 97803 should be unit priced; four units = 60 minutes, and six units = 90 minutes. Medicare will cover 3 hours (12 units) of nutrition counseling in the first year of working with a patient, and 2 hours (8 units) of nutrition counseling in subsequent years.
Medicare will cover up to 8 units for an initial session (97802) and up to 4 units (97803) for a follow-up session. Due to the time and care required during an initial session, 97802 is typically reimbursed at a higher rate per unit. However, keep in mind that the total billable time is 12 units in the first year. Many dietitians choose to split up this time, via shorter sessions, so that clients can check in more frequently. In addition, If your client’s status has changed (ie they have a new diagnosis, or are now on insulin), then CPT code G0270 may be used for an additional 8 units (120 minutes) of counseling.
- G0270 — Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease), individual, face-to-face with the patient, each 15 minutes
Once your client has run out of covered benefits for the year, then you may want to present them with the option to self-pay for further nutritional care sessions. Their benefits will renew for the benefits year, at which time they can return to using their Medicare benefits until once again exhausted.
What Does Medicare Pay for MNT Services?
Once you sign your contract with Medicare, you’ll be provided a fee schedule for which you can look up the reimbursement rate for CPT codes 97802, 97803, and G0270. Medicare is the only insurance payer to make this information public — for any other insurance payer that you contract with, rates are private and not to be disclosed to any other wellness professional. As they are public, Medicare rates can be found online via their Fee Schedule, with rates varying based on state and code billed. Keep in mind, the reimbursement rate is PER UNIT (ie. if the reimbursement rate in your area is $44.01 per unit, then you will be paid $44.01 for every 15 minutes you spend with client).
You may not bill Medicare for any time spent outside of your nutrition counseling session. Any time spent reading client charts, connecting with other wellness providers, creating meal plans, answering client emails, etc is not considered billable time. Visit this post for more information on creating add-on services in your insurance-based nutrition practice.
Billing Medicare Supplemental Plans
You may find that many wellness clients don’t have straight Medicare B, but instead a supplemental plan (indicated as “Supplement” on their card). For example, Blue Cross Medicare Advantage Plan. If you are not in-network with Medicare, but are in-network with the private payer (ie Blue Cross) you will not be reimbursed for the services. Clients who use their supplemental plan, must still meet the diagnosis criteria in order to use their benefits.
In short, you’ll only be reimbursed for clients that have UHC Medicare Advantage if you already are in-network with Medicare, and the client has diabetes or renal disease.
Billing Medicare for Telehealth Nutrition Services
Current law only permits Medicare to pay for telehealth services that are provided to a client who is present (at the time of care) in an “originating site located in certain types of geographic areas” including:
- a rural health professional shortage area (HPSA)
- a county outside of a Metropolitan Statistical Area (MSA)
- or a site that is participating in a Federal telemedicine demonstration project approved by (or receiving funding from) the Secretary of Health and Human Services
In addition, current law only allows certain types of healthcare settings to serve as originating sites:
- offices of physicians or practitioners
- hospitals, critical access hospitals
- rural health clinics
- federally qualified health centers
- hospital-based critical access
- hospital-based renal dialysis centers (including satellites)
- skilled nursing facilities
- Community mental health centers.
The statute only allows certain types of wellness practitioners to bill and receive Medicare reimbursement for telehealth services, which includes registered dietitians and nutrition professionals.
According to a 2019 List of Medicare Telehealth Services, individual and group nutrition therapy services may be covered for virtual when using the following billing codes: HCPCS code G0270 and CPT codes 97802–97804
Leveraging Healthie for Medicare Billing
Healthie is an all-in-one practice management and EHR platform for nutrition and wellness professionals. Have all of the tools you need to run your practice, with flexible billing tools for both insurance-based practice and self-pay services. Healthie’s HIPAA-compliant features allow you to:
- Create new client paperwork for clients to complete electronically
- Use and customize nutrition charting templates
- Create and submit CMS1500 claims
- Send and receive E-Fax documents
- Create invoices and process client payments for self-pay services
- Provide clients with a login access so they can securely message you, complete E-paperwork, upload documents, and keep a photo-based food journal
Make more time to grow your business.
Use a platform that automates the administrative, so you can focus on growth and care.