This document attempts to frame out and create a guideline for certain coding and documentation protocols that should be considered when performing nutritional counseling and like services provided by Licensed Doctors. Billing and coding decisions should not be solely based upon information contained in this summary. Individual circumstances (i.e. whether nutritional counseling is within the scope of practice in your state), legal and ethical considerations as well as payer policies should always be considered when determining a particular course of action.

This coding summary for nutritional counseling and like services has been developed for licensed doctors and is not intended for use by registered dieticians and other nutritional specialists. Its purpose is to provide some basic coding suggestions and observations in regards to nutritional counseling by licensed doctors. When determining how to code for nutritional counseling services, providers must assess whether the patient is presenting with actual symptoms and/or an established illness or whether the patient is merely seeking preventative services. Providers who bill based on coverage or payment rather than medical necessity are at significant risk of post-payment recovery to the carrier where it can be shown that the billing, and the resulting separate payment, is not justified by the documentation or circumstances of treatment.

Often times licensed doctors code for nutritional counseling services based on the Medical Nutrition Therapy (MNT) codes 97802-97804. However, according to CPT this is not the correct way to bill for theses services by licensed doctors. The in November of 2003 the AMA CPT Assistant stated the following:

"Medical Nutrition Therapy", CPT Assistant, American Medical Association, November 2003, Vol. 13, Issue 11, p. 1 (Emphasis Added).

So how should licensed doctors bill for this service? Doctors should bill for nutritional counseling using the Evaluation and Management service (E/M) codes, e.g. office or other outpatient visit 99201-99215 codes. This type of service is typically considered a "counseling" component to the overall E/M service chosen. Counseling includes the following components:

"Counseling and/or Coordination of Care", CPT Assistant, American Medical Association, August 2004, Vol. 14, Issue 08, p. 1 (Emphasis Added).

As stated above, if counseling and/or coordination of care dominate the visit, then the level of E/M is selected based on the total time of the face-to-face physician/patient time. Documentation requirements for counseling are critical to determining the level of service and coding correctly. The doctor must include a record of total time of the visit as well as the time spent in the specific counseling or coordination of care activities. The note should also include a description of the type and content of the counseling that occurred.

If counseling and/or coordination of care did not constitute more than 50% of the face-to face doctor/patient encounter, then the level of service is selected on the basis of the key components (i.e., history, examination, and medical decision making) and counseling is only contributory to the key components. Providers are strongly encouraged to thoroughly review either the 1995 or 1997 Documentation Guidelines for Evaluation and Management Services published by the Centers for Medicare and Medicaid Services (CMS).

So how should licensed doctors code for nutritional counseling when a patient presents with no underlying condition and is looking for services that would most likely be couched as "preventative"?

When a patient presents with no actual symptoms and/or an established illness then the provider should look to the Preventive Medicine, Individual Counseling E/M codes. They are from the 99401 - 99412 series of CPT codes and are used to report counseling services provided to individuals at a separate encounter for the purpose of promoting health and preventing illness or injury. The AMA explains these services (emphasis added):

"Coding for Counseling", CPT Assistant, American Medical Association, January 1998, Vol. 8, Issue 01, p. 5 (Emphasis Added).

Current Procedural Terminology (CPT) defines these codes as:

Preventive Medicine, Group Counseling (for more than one individual at the same time):

When choosing the correct diagnosis for a patient that presents with actual symptoms and/or an established illness, the doctor needs to look at the chief complaint(s), and contributing condition(s) that support the rationale behind counseling the patient. Typically patients that fall into this category would, in addition to their chief complaint/medically necessary diagnosis, also have a contributing condition such as obesity, diabetes, etc.

However, if a patient is presenting to your office with no particular complaint and wants "preventative services" then it is suggested the provider consider using "V" codes. V codes are diagnosis codes that are defined as "Supplementary Classification of Factors Influencing Health Status and Contact with Health Services (V01-V85)". This classification of codes is provided for situations other than a disease or injury. One of the circumstances that "V" codes are defined as:

International Classification of Diseases 9th Revision, Clinical Modification 6th Edition, 2006 Volume 1; Published by Practice Management Information Corporation (PMIC)

A couple of examples of V codes that may be appropriate for patients that presents without symptoms or established illness is:

The steps to properly billing and coding for nutritional counseling in your practice should always be based on Patient needs and proper coding rules. As stated above, coverage should never determine how a provider should bill for services provided to the patient. Will carriers pay for the preventative medicine codes? Medicare does not pay for preventative medicine services and most carriers follow Medicare's lead. Having stated the above, certain policies may have provisions that allow preventative medicine services to be paid. However, the majority of the time patients will be directly responsible for payment.

When determining the appropriate fee for this service, it is suggested providers base those fees largely on time spent face-to-face with the patient, as this is a determining factor in the very definition of the preventative medicine codes.

If you have any questions or comments in regards to this summary, please feel free to contact David Klein at (215) 947-2377.

Resources:

1. American Medical Association (AMA), CPT- 4 Current Procedural Terminology Manual (Version in Effect).
2. Centers for Medicare and Medicaid Services (CMS) 1995 Documentation Guidelines for Evaluation and Management Services
3. American Medical Association (AMA) CPT Assistant Archives 1990-2005.
4. International Classification of Diseases 9th Revision, Clinical Modification 6th Edition, (Version in Effect) Volumes 1&2; Published by PMIC.