Medical_Policy

Mountain State Medical Policy Bulletin

Section:	Visits
Number:	V-44
Topic:	Medical Nutrition Management Services (MNT)
Effective Date:	September 10, 2007
Issued Date:	September 10, 2007
Date Last Reviewed:	03/2007

General Policy Guidelines

Indications and Limitations of Coverage

When reported separately, charges for medical nutrition therapy (97802, 97803, 97804, G0270, G0271) should be combined with and processed under the appropriate medical visit procedure codes. If MNT is the only service performed, it will be reimbursed in accordance with the member's medical care benefits.

Medical nutrition therapy (MNT) is covered for the following diagnoses/conditions. This list includes those diagnoses/conditions that most commonly benefit from MNT in improving desired health outcomes. (This is not intended to be an all-inclusive list.)

042	Human immunodeficiency virus (HIV) disease
250.00-250.93	Diabetes mellitus
260, 261, 262, 263.0-263.9, 264.0-264.9, 265.0-265.2, 266.0-266.9, 267, 268.0-268.9, 269.0-269.9	Nutritional deficiencies
270.0-270.9	Disorders of amino-acid transport and metabolism
272.0-272.9	Disorders of lipid metabolism
275.0-275.3, 275.40-275.49, 275.8, 275.9	Disorders of mineral and calcium metabolism
276.1	Hyponatremia
276.7	Hyperpotassemia
276.8	Hypopotassemia
277.00-277.09	Cystic fibrosis
277.81-277.89, 277.9	Other specified disorders of metabolism
278.01	Morbid obesity
307.1, 307.50-307.59	Anorexia nervosa and eating disorders
345.00-345.91, 780.39	Epilepsy and other convulsive disorder
401.0-401.9, 402.00-402.91, 403.00-403.91, 404.00-404.93, 405.00-405.99	Hypertensive disease
410.00-410.92, 411.0-411.1, 411.81-411.89, 412, 413.0-413.9, 414.00-414.07, 414.10-414.19, 414.8, 414.9	Ischemic heart disease
416.0-416.9	Chronic pulmonary heart disease
425.0-425.9	Cardiomyopathy
428.0-428.1, 428.20-428.23, 428.30-428.33, 428.40-428.43, 428.9	Heart failure
429.0	Myocarditis
429.1	Myocardial degeneration
429.2	Cardiovascular disease
429.3	Cardiomegaly
531.00-531.91, 532.00-532.91, 533.00-533.91, 534.00-534.91, 535.00-535.61	Gastric ulcer, duodenal ulcer, peptic ulcer, gastrojejunal ulcer, gastritis and duodenitis
536.0-536.3, 536.40-536.49, 536.8, 536.9, 537.0-537.6, 537.81-537.89, 537.9	Disorders of function of stomach and gastrostomy complications and other disorders of stomach and duodenum
555.0-560.2, 560.30-560.39, 560.81-560.89, 560.9, 562.00-562.03, 562.10-562.13, 564.00-564.09, 564.1-564.7, 564.81-564.89. 564.9	Regional enteritis, ulcerative colitis, vascular insufficiency of intestine, other and unspecified noninfectious gastroenteritis and colitis, intestinal obstruction, diverticula of intestine, and functional digestive disorders
569.60-569.69, 569.81-569.89, 569.9	Colostomy and enterostomy complications, and other specified disorders of the intestines
570, 571.0-571.3, 571.40-571.49, 571.5-571.9, 572.0-572.8, 573.0-573.9, 574.00-574.91, 575.10-575.12, 575.2-575.9, 576.0, 576.9, 577.0-577.9, 578.0-578.9, 579.0-579.9	Liver diseases, cirrhosis, and other diseases of the digestive system
580.0-580.4, 580.81-580.89, 580.9, 581.0-580.3, 581.81-581.89, 581.9, 582.0-582.4, 582.81-582.89, 582.9, 583.0-583.7, 583.81-583.89, 583.9, 584.5-585.9, 586, 587, 588.0, 588.1, 588.81-588.89, 589.0-589.9, 590.00-590.01, 590.10-590.11, 590.2-590.3, 590.80-590.81, 590.9, 591, 592.0-593.6, 593.70-593.89, 593.9, 594.0-594.9, 595.0--595.4, 595.81-595.89, 595.9, 596.0-596.4, 596.51-596.59, 596.6-597.0, 597.80-597.89, 598.00-598.01, 598.1-599.5, 599.60-599.69, 599.7, 599.81-599.84, 599.9	Glomerulonephritis, nephrotic syndrome, nephritis, renal failure, infections of kidney, calculus of kidney and ureter, and disorder of bladder
642.00-642.94	Hypertension complicating pregnancy, childbirth, and the puerperium
648.80-648.84	Gestational diabetes
733.00-733.09	Osteoporosis
751.0-751.5, 751.60-751.69, 751.7-751.9	Congenital anomalies of the digestive system
753.0, 753.10-753.29, 753.3	Congenital anomalies of kidney
783.0-783.1, 783.21-783.22, 783.3, 783.40-783.43	Symptoms concerning nutrition, metabolism and development

Claims for MNT with diagnoses/conditions other than those listed above are not medically necessary and are not eligible for coverage. A participating, preferred, or network provider cannot bill the member for the denied service. Individual consideration can be given if this decision is questioned.

See Medical Policy Bulletin Z-27 for information on eligible providers.

See Medical Policy Bulletin G-24 for information on the treatment of obesity.

See Medical Policy Bulletin E-15 for information on Diabetic Services and Supplies.

NOTE:: This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Description

Medical Nutrition Therapy (MNT) is an important part of prevention and treatment of many diseases and conditions. MNT is the assessment of the patient’s nutritional status followed by therapy. The overall goal of MNT is to assist the patient in making changes in his/her nutrition and exercise habits leading to improved health through optimal nutrition. MNT may be performed as an outpatient service in a professional provider's office, in an outpatient facility or in the patient's home.

A MNT assessment may include the review and analysis of the following:

Medical, nutrition, and medication histories
Physical examination
Anthropometric measurements
Laboratory test values

Medical Nutrition Therapy (MNT) can include the following:

Diet modification
Counseling and education
Disease self-management skills training
Education/Instruction of specialized therapies such as medical foods, intravenous, or tube feedings

Procedure Codes

97802

97803

97804

G0270

G0271

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program.

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

American Dietetic Association: disorders of lipid metabolism: evidence-based nutrition practice guidelines, American Dietetic Association, 08/2005

American Dietetic Association: chronic kidney disease (non-dialysis) medical nutrition therapy protocol, American Dietetic Association, 05/2002

Position of the American Dietetic Association and Dietitians of Canada: nutrition intervention in the care of persons with human immunodeficiency virus infection, Journal of the American Dietetic Association, Vol. 104, No. 9, 09/2004

Advocacy for coverage of nutrition services, Journal of the American Dietetic Association, Vol. 105, No.5, 05/2005

Nutritional assessment and counseling for prevention and treatment of cardiovascular disease, American Family Physician, Vol. 73, No. 2, 01/2006

Effectiveness of medical nutrition therapy: importance of documenting and monitoring nutrition outcomes, Journal of the American Dietetic Association, Vol. 106, No. 9, 12/2004

Position of the American Dietetic Association: nutrition intervention in the treatment of anorexia nervosa, bulimia nervosa, and other eating disorders, Journal of the American Dietetic Association, Vol. 106, Number 12, 12/2006

American Dietetic Association: standards of practice in nutrition care and updated standards of professional performance, Journal of the American Dietetic Association, Vol. 105, No. 4, 04/2005

Impact of gestational diabetes mellitus nutrition practice guidelines implemented by registered dietitians on pregnancy outcomes, Journal of the American Dietetic Association, Vol. 106, No. 9, 09/2006

Position paper of the American Dietetic Association: nutrition across the spectrum of aging, Journal of the American Dietetic Association, Vol. 105, No. 4, 04/2005

Position of the American Dietetic Association and Dietitians of Canada: nutrition and women’s health, Journal of the American Dietetic Association, Vol. 104, No. 6, 06/2004

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Glossary

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.