Nutritional Counseling Services

Last Review Date: September 8, 2023 Number: MG.MM.AD.09bC4

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meets the criteria for the treatment or surgical procedure. Without this documentation and information, EmblemHealth will not be able to properly review the request

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EmblemHealth established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer

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Definition

Medical Nutrition Therapy involves the assessment of an individual’s overall nutritional status followed by an

individualized course of treatment to prevent or treat medical illness. Nutritional counseling considers many factors

including a person’s food intake, physical activity, course of any medical therapy including medications and other

treatments, and individual preferences.

Guideline

Members are eligible for nutritional counseling as a necessary therapeutic component in disease management when

dietary strategy and intervention are known to positively impact clinical outcomes.

Conditions amenable to dietary intervention are listed in the Applicable Diagnosis Codes

section below.

Utilization

A. Parameters for diabetes self-management training (DSMT)

a. Initial training — provided only once (10 hours total within 12-month period) consisting of:

i. 9 hours within a group of 2–20 participants

ii. 1 hour of individual training to assess member-needs

iii. Each class ≥ ½ hour

b. Follow-up Training — ≤ 2 hours of individual or group training per year (each class ≥ ½ hour) — group

may be 2–20 people and either:

i. Furnished in the calendar year post IT year

ii. Furnished when ordered (even in the absence of documentation that IT has been received)

c. Group participation exception — training may be individual if:

i. No group training is available within 2 months of order

ii. The provider documents that member’s special needs (e.g., severe hearing, language or vision

limitations) will hinder effective group participation

B. Parameters for medical nutrition therapy (MNT)

a. Initial assessment visit

b. Follow-up intervention visits

c. Reassessments as necessary during 12-month episode of care to assure compliance with dietary plan.

Limitations/Exclusions

1. Nutritional counseling is not considered medically necessary for any of the following:

a. Conditions unrelated to dietary management (e.g., attention deficit disorders, asthma, chronic fatigue

syndrome, etc. [list not all inclusive)

b. General educational purposes

2. Services must be prescribed by a physician and furnished by a provider credentialed by plan.

3. Use of an online electronic-structured intensive program for behavior change (CPT 0488T) is not considered

medically necessary.

Revision History

Feb. 16, 2022 Time-allowance parameters removed for MNT

Sept. 13, 2019 Follow-up training time-allowance for MNT expanded from 2 to 3 hours

Applicable Procedure Codes

0403T

Preventive behavior change, intensive program of prevention of diabetes using a standardized diabetes prevention

program curriculum, provided to individuals in a group setting, minimum 60 minutes, per day (cover for Medicaid only)

97802 Medical nutrition therapy; initial assessment and intervention, individual face-to-face with the patient, each 15 minutes

97803 Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes

97804 Medical nutrition therapy; group (2 or more individual(s) each 30 minutes

98960

Education and training for patient self-management by a qualified, nonphysician health care professional using a

standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient

98961

Education and training for patient self-management by a qualified, non-physician health care professional using a

standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; 2-4 patients

98962

Education and training for patient self-management by a qualified, non-physician health care professional using a

standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; 5-8 patients

99078

Physician or other qualified health care professional qualified by education, training, licensure/regulation (when applicable)

educational services rendered to patients in a group setting (eg, prenatal, obesity, or diabetic instructions)

G0108 Diabetes outpatient self-management training services, individual, per 30 minutes

G0109 Diabetes outpatient self-management training services, group session, (2 or more), per 30 minutes

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 (cover for Medicare only)

G0271

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), group (2 or

more individuals), each 30 minutes (cover for Medicare only)

G0447

Face-to-face behavioral counseling for obesity, 15 minutes (cover for Medicare only)

G0473

Face-to-face behavioral counseling for obesity, group (2-10), 30 minutes (cover for Medicare only)

S9452 Nutrition classes, nonphysician provider, per session

S9455 Diabetic management program, group session

S9460 Diabetic management program, nurse visit

S9465 Diabetic management program, dietitian visit

S9470 Nutritional counseling, dietitian visit

Applicable ICD-10 Diagnosis Codes

B25.1 Cytomegaloviral hepatitis

B25.2 Cytomegaloviral pancreatitis

B52.0 Plasmodium malariae malaria with nephropathy

E08.00

Diabetes mellitus due to underlying condition with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar

coma (NKHHC)

E08.01 Diabetes mellitus due to underlying condition with hyperosmolarity with coma

E08.10 Diabetes mellitus due to underlying condition with ketoacidosis without coma

E08.11 Diabetes mellitus due to underlying condition with ketoacidosis with coma

E08.21 Diabetes mellitus due to underlying condition with diabetic nephropathy

E08.22 Diabetes mellitus due to underlying condition with diabetic chronic kidney disease

E08.29 Diabetes mellitus due to underlying condition with other diabetic kidney complication

E08.311 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema

E08.319 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy without macular edema

E08.3211

Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema,

right eye

E08.3212

Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema,

left eye

E08.3213

Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema,

bilateral

E08.3219

Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema,

unspecified eye

E08.3291

Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular

edema, right eye

E08.3292

Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular

edema, left eye

E08.3293

Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular

edema, bilateral

E08.3299

Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular

edema, unspecified eye

E08.3311

Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular

edema, right eye

E08.3312

Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular

edema, left eye

E08.3313

Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular

edema, bilateral

E08.3319

Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular

edema, unspecified eye

E08.3391

Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular

edema, right eye

E08.3392

Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular

edema, left eye

E08.3393

Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular

edema, bilateral

E08.3399

Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular

edema, unspecified eye

E08.3411

Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema,

right eye

E08.3412

Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema,

left eye

E08.3413

Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema,

bilateral

E08.3419

Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema,

unspecified eye

E08.3491

Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular

edema, right eye

E08.3492

Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular

edema, left eye

E08.3493

Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular

edema, bilateral

E08.3499

Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular

edema, unspecified eye

E08.3511 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, right eye

E08.3512 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, left eye

E08.3513 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, bilateral

E08.3519

Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema,

unspecified eye

E08.3521