Medical Nutrition Therapy (MNT)

Reimbursement Policy:
Medical Nutrition Therapy (MNT)

Effective Date:
April 15, 2021

Purpose:
To provide guidelines for the proper use and reimbursement of Medical Nutrition Therapy.

Scope:
The guidelines of this policy content apply to claims for members enrolled in all insured commercial plans, Medicare Advantage Plans (including Braven Health plans), and Administrative Services Only (ASO) employer group plans that have opted-in to these guidelines, including the State Health Benefits Program/School Employees’ Health Benefits Program (SHBP/SEHBP). ASO group accounts may opt-in for their members on an account-by-account basis.

Members enrolled in the following plans/products/programs are excluded from the guidelines of this policy:

Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
COB
ITS Home In-Network
FEP
Horizon NJ Health plans (Medicaid Managed Care, NJ FamilyCare, Horizon NJ TotalCare (HMO D-SNP), Managed Long Term Services & Supports program)

Definitions:
MNT Procedure codes:

97802 MNT, initial assessment and intervention, individual, each 15 minutes

97803 MNT, reassessment and intervention, individual, each 15 minutes

97804 MNT, group, each 30 minutes

G0270 MNT, reassessment and subsequent intervention following second referral in same year for change in diagnosis, medical condition or treatment regimen, individual, each 15 minutes

G0271 MNT, reassessment and subsequent intervention following second referral in same year for change in diagnosis, medical condition or treatment regimen, group, each 30 minutes

Policy:
In accordance with CMS guidelines, which Horizon hereby deems is appropriate to be applicable to all of its lines of business, these services (all of the above codes) will only be deemed covered and payable when billed by a registered dietician, nutritional professional or when billed by a hospital that has received assignment from a registered dietician or nutritionist. These services may not be paid "incident to" physician services.

Further, 97802 (individual) may only be used once for the initial assessment of a new patient. Subsequent visits should be billed using 97803 (individual) or 97804 (group). CMS National Correct Coding Initiative does not allow a provider to bill more than one MNT code per date of service. Modifiers will not bypass these code combinations. MNT services shall not considered for reimbursement when submitted by a provider other than a registered dietician, nutritional professional or hospital.

Horizon BCBSNJ shall limit the units of 97803 eligible for reimbursement when billed greater than 11 units within the same calendar year.

Additional units of 97802, 97803 and 97804 shall not be considered for reimbursement when greater than 12 combined units have been billed within a calendar year.

The procedure codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.

Procedure:
Horizon BCBSNJ shall deny MNT services (97802-97804 or G0270-G0271) when billed by a provider other than a registered dietician, nutritional professional, or hospital.

Procedure code 97803 shall be denied when greater than 11 units have been billed within the same calendar year

97802, 97803 or 97804 shall be denied when greater than 12 combined units have been billed within a calendar year. No additional reimbursement shall be made if the provider is capitated or the reimbursement structure for that provider is a global fee.

In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.

In instances where the provider is not participating, member liability shall be up to the provider’s charge.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

Group or Individual benefit
Provider Participation Agreement
Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
Mandated or legislative required criteria will always supersede.

History:
12/21/2020: Policy approved

Policy142_v1.0_12212020