Demystifying CPT Code 97802, CPT Code 97803, Modifiers, and More For Dietitian Superbills
May 02, 2023
If you’ve ever created a Superbill through your dietitian practice you already know there’s a lot of information you need to get right. From ensuring accurate patient details to inputting the correct nutrition CPT codes, modifiers, and diagnosis codes, there are many moving parts to manage. Making errors can have financial or legal consequences with the potential to erode client confidence.
For those practitioners who aren’t familiar with the concept of a Superbill, you can think of it as a standardized, detailed invoice provided to clients as a receipt after they’ve paid for your services. They’re commonly used if you don’t accept insurance in your practice or are “out of network” for your client’s insurance plan. The client submits the Superbill to their insurance company as part of the reimbursement collection process. Check out this Super Guide to Superbills post if you’d like to learn more.
Even dietitian practitioners who have experience creating Superbills or submitting insurance claims directly to payors may find it challenging to keep on top of which nutrition CPT codes to use for the services they provide, which can be updated annually.
When do you use CPT Code 97802?
How does it differ from CPT code 97803?
How do diagnosis codes and modifiers fit into the mix?
Not to worry – help is here! Consider this blog your one-stop source for the most common CPT, diagnosis, and modifier codes used in nutritional services. Read it now and bookmark it for easy reference later. Don’t forget to hit the link at the bottom of the post to download our cheat sheet designed to help you create clear and comprehensive insurance billing claims or Superbills, every time.
CPT stands for Current Procedural Terminology. It’s a collection of standardized codes used by healthcare professionals to streamline reporting, billing, and payment for procedures and services. CPT codes are maintained and updated by the American Medical Association (AMA).
The three CPT codes dietitians use most often fall under Medical Nutrition Therapy, or MNT. These codes are accepted by private insurance carriers and public insurers, like Medicare and Medicaid:
Don’t forget that CPT codes are time-based. A unit of time is reached when your appointment passes the midpoint. For example, if you were billing under the 97802 CPT code for dietary counseling that would mean you must spend at least 8 minutes with a client to bill for one unit. Billing for two units requires spending at least 23 minutes with your client (the first 15 minutes + 8 more to get past the midpoint of the second unit).
For CPT code 97804 you need to spend at least 16 minutes with a client to bill for a single unit, or 46 minutes to bill for two units (30 minutes + 16 to get past the midpoint of the second unit).
Overall, the number of units you can bill for each of the above nutrition CPT codes may vary depending on the insurance provider, state regulations, and other factors. If you’re making direct claims it’s best to check with the appropriate provider to confirm coverage.
It’s important that you select the right CPT code for dietary counseling the first time, as incorrect codes can lead to payment delays, under- or over-payment, and even claim denials. One way to reduce things like transcription errors is to add your commonly used codes to your Practice Better account to more easily create a Superbill.
Modifier codes are two-digits that you can add to CPT codes to provide additional information about the services provided. They are used to indicate that a service or procedure has been altered in some way, or to indicate other unique circumstances related to the service provided.
For example, you can add the modifier code 95 to CPT codes for dietary counseling to indicate that counseling services were provided via Telehealth. Or, if you believe services performed won’t be covered, the modifier code GA indicates that the patient is aware, still wants the services performed, and agrees to pay for any denied charges.
CPT codes and ICD-10 (International Statistical Classification of Diseases) codes are both used in medical billing and coding, but they serve different purposes. In the simplest terms, CPT codes describe WHAT was done (think: procedures and services), while ICD-10 codes describe WHY it was done (think: diagnoses and conditions).
Unlike the CPT codes for nutritional counseling that are maintained by the AMA, ICD-10 codes are maintained and updated by the World Health Organization (WHO). In addition to insurance companies using the codes to determine necessity and provide a basis for payment, ICD-10 codes also have a research and statistical purpose. According to the WHO, data that’s reported and coded with the ICD “provides critical knowledge on the extent, causes and consequences of human disease and death worldwide.”
On a Superbill, ICD-10 codes are usually included in a section labeled “Diagnosis” or “Reason for Visit”. You need to select the code(s) that accurately describe the client’s medical condition or diagnosis. CPT codes would typically be entered in a separate section, labeled “Services Provided” or “Procedure Codes”. Specific code entry locations will depend on the format and layout of the Superbill.
If a client is coming to you directly, you need to identify the primary reason for the visit or consultation, and select the code from the ICD-10 set that best describes the patient’s condition or diagnosis. You can find the appropriate ICD-10 code through The Academy of Nutrition and Dietetics. The Center for Disease Control and Prevention (CDC) also offers a handy look-up tool.
If a primary care provider is referring a client to you, they should be providing the ICD-10 diagnosis code based on their assessment of the client’s medical condition. A common diagnosis code medical providers use is Z71.3 for Dietary Counseling and Surveillance. It’s often associated with people who have chronic conditions – like diabetes, hypertension, or obesity – who could benefit from counseling on appropriate nutrition and dietary changes to help manage their medical conditions.
You’ll want to verify that the diagnosis code provided by the referring medical professional is accurate and appropriate for the client’s condition. You should also take care to document any additional assessment or evaluation that you perform as it can help to support the medical necessity of the services provided and facilitate reimbursement from insurance or other reimbursement programs.
Medicare and Medicaid programs don’t accept the Superbill format. Instead, they require practitioners to submit claims for services using specific billing forms, like CMS-1500. The specific form required for Medicaid submissions may also depend on the type of services provided and the state where the services were rendered. Some states have their own Medicaid billing forms.
Despite the differences in submission requirements, Medicare and Medicaid both use CPT and ICD-10 codes for billing and reimbursement. However, there are some nuances you should be aware of.
Medicare Part B is a part of the federal Medicare program that provides coverage for certain medically necessary services and supplies that are not covered under Part A (hospital insurance). MNT services are 100% covered under Medicare Part B if clients have one of the following conditions:
Nutritional counseling can also be covered if one of these comorbidities is present. Part B will also cover obesity screenings and behavioral counseling for clients with a BMI of 30 or higher.
Note that full Medicare coverage requires a physician referral. Medicare will cover three hours of MNT for the first year and two hours in the years that follow. You would use your standard nutritionist CPT codes for these claims, such as the 97802 CPT code discussed earlier. If you’ve exhausted a client’s benefits for a calendar year, but the referring physician deems more hours are needed due to a change in the client’s condition, then you can use G codes on claims for the rest of that year.
Medicaid MNT coverage varies by state, which can be challenging to navigate. Some states don’t recognize registered dietitians as approved providers. States are required by federal law to provide “mandatory” benefits. This includes services like inpatient and outpatient hospital services, physician services, laboratory and x-ray services, and other “optional” benefits like prescription drugs, case management, physical therapy, and occupational therapy, which can also be covered by Medicaid. Coverage for nutritional services is not included on the list of mandatory or optional benefits.
It’s wise to check with your state Medicaid agency to find out what’s covered before providing services to clients.
Navigating the sometimes-choppy waters of reimbursement can be frustrating and time consuming. But it’s important to get your CPT codes, diagnosis codes, and modifiers right the first time to avoid payment, compliance, and client experience snags.
We know there’s a lot to take in, so we’ve created a cheat sheet you can use as a resource to help you select the correct codes and keep reimbursement flowing smoothly. Download our CPT Code Cheat sheet for dietitians and print it out for easy reference.
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