Medical Nutrition Therapy Billing Guide
Washington Apple Health (Medicaid)Medical NutritionTherapy BillingGuideOctober 1, 2020
DisclaimerEvery effort has been made to ensure this guide’s accuracy. If an actual orapparent conflict between this document and an HCA rule arises, HCA rulesapply.Billing guides are updated on a regular basis. Due to the nature of contentchange on the internet, we do not fix broken links in past guides. If you find abroken link, please check the most recent version of the guide. If this is the mostrecent guide, please notify us at askmedicaid@hca.wa.gov.About this guide *This publication takes effect October 1, 2020, and supersedes earlier billingguides to this program. Unless otherwise specified, the program in this guide isgoverned by the rules found in Chapter 182-555 WAC.The Health Care Authority is committed to providing equal access to our services.If you need an accommodation or require documents in another format, pleasecall 1-800-562-3022. People who have hearing or speech disabilities, please call711 for relay services.Washington Apple Health means the public health insuranceprograms for eligible Washington residents. Washington AppleHealth is the name used in Washington State for Medicaid, thechildren’s health insurance program (CHIP), and state-onlyfunded health care programs. Washington Apple Health isadministered by the Washington State Health Care Authority.Refer also to HCA’s ProviderOne billing and resource guide for valuableinformation to help you conduct business with the Health Care Authority.How can I get HCA Apple Health provider documents?To access provider alerts, go to HCA’s provider alerts webpage.To access provider documents, go to HCA’s provider billing guides and feeschedules webpage.Where can I download HCA forms?To download an HCA form, see HCA’s Forms & Publications webpage. Type onlythe form number into the Search box (Example: 13-835).*This publication is a billing instruction.CPT codes and descriptions only are copyright 2019 American Medical Association.2 MEDICAL NUTRITION THERAPY BILLING GUIDE
Copyright disclosureCurrent Procedural Terminology (CPT) copyright 2019 American MedicalAssociation (AMA). All rights reserved. CPT is a registered trademark of the AMA.Fee schedules, relative value units, conversion factors and/or related componentsare not assigned by the AMA, are not part of CPT, and the AMA is notrecommending their use. The AMA does not directly or indirectly practicemedicine or dispense medical services. The AMA assumes no liability for datacontained or not contained herein.What has changed?SubjectChangeReason for ChangeEntire GuideRevised format ofentire guide.To comply withaccessibility standards.Apple Health Changesfor January 1, 2020Removed AppleHealth Changessection.This section isunnecessary, as it isoutdated. All regions arenow fully integratedmanaged care.Integrated managedcare regionsRemoved listing ofregions and theirintegration dates.This section isunnecessary, as it isoutdated. All regions arenow fully integratedmanaged care.CPT codes and descriptions only are copyright 2019 American Medical Association.3 MEDICAL NUTRITION THERAPY BILLING GUIDE
Table of ContentsResources Available. 5Definitions . 6About the Program . 8What is the purpose of the medical nutrition therapy program? . 8Client Eligibility. 9Who is eligible for Medical Nutrition Therapy? . 9How do I verify a client’s eligibility? . 9Verifying eligibility is a two-step process: . 9Are clients enrolled in an HCA-contracted managed care organization (MCO)eligible? . 10Managed care enrollment . 11Clients who are not enrolled in an HCA-contracted managed care plan forphysical health services . 12Integrated managed care . 12Integrated Apple Health Foster Care (AHFC) . 13Fee-for-service Apple Health Foster Care . 13Provider Requirements . 14Who may provide and bill for medical nutrition therapy? . 14When may providers bill HCA for medical nutrition therapy provided in WICprogram locations? . 14Who can refer a client for medical nutrition therapy? . 14What are the responsibilities of the registered dietitian (RD) regarding thereferral? . 15When does HCA cover telemedicine? . 15Coverage/Fee Schedule . 16What is covered? . 16Fee Schedule . 16Billing . 17What are the general billing requirements? . 17What additional documentation must be kept when providing medicalnutrition therapy? . 18What additional information must be included in the enteral nutritionevaluation when clients are receiving enteral nutrition product paid for byHCA? . 18How do I bill claims electronically? . 18CPT codes and descriptions only are copyright 2019 American Medical Association.4 MEDICAL NUTRITION THERAPY BILLING GUIDE
Resources AvailableTopicResourceBecoming a provider or submitting a change ofaddress or ownershipSee HCA’s ProviderOne Resourceswebpage.Contacting Provider EnrollmentSee HCA’s ProviderOne Resourceswebpage.Finding out about payments, denials, claimsprocessing, or HCA managed care organizationsSee HCA’s ProviderOne Resourceswebpage.Electronic billingSee HCA’s ProviderOne Resourceswebpage.Finding HCA documents (e.g., billing guides, feeschedules)See HCA’s ProviderOne Resourceswebpage.Private insurance or third-party liability, otherthan HCA-contracted managed careSee HCA’s ProviderOne Resourceswebpage.Access E-learning toolsSee HCA’s ProviderOne Resourceswebpage.CPT codes and descriptions only are copyright 2019 American Medical Association.5 MEDICAL NUTRITION THERAPY BILLING GUIDE
DefinitionsThis section defines terms and abbreviations, including acronyms, used in thisbilling guide. Refer to chapter 182-500 WAC and WAC 182-555-0200 for acomplete list of definitions for Washington Apple Health.Benefit Service Package - A grouping of benefits or services applicable to aclient or group of clients.Note: Registered Dietitians licensed in the State of Oregon maybe assigned an HCA-Certified Dietitian ProviderOne ID/NPI.Enteral Nutrition – The use of medically necessary nutrition products alone, or incombination with traditional food, when a client is unable to consume enoughtraditional food to meet nutrition requirements. Enteral nutrition solutions can begiven orally or via feeding tubes. WAC 182-554-200Enteral Nutrition Product - Enteral nutrition formulas and/or products.WAC 182-554-200Maximum Allowable - The maximum dollar amount that a provider may bereimbursed by HCA for specific services, supplies, or equipment.Medical Nutrition Therapy - An interaction between the registered dietitian(RD) and the client or client's guardian for the purpose of evaluating and makingrecommendations regarding the client's nutritional status.Nutrition assessment- As part of the Nutrition Care Process, NutritionAssessment is the collection, interpretation and documentation of informationnecessary to evaluate nutrition status, needs, and interventions. The informationincludes food or nutrition-related data; biochemical data, medical tests andprocedures; anthropometric measurements, nutrition-focused physical findingsand client history.Nutrition care process - A systematic approach to providing high-qualitynutrition care. Provides a framework for the registered dietitian (RD) toindividualize care, taking into account the client's needs and values and evidenceavailable to make decisions.Nutrition-related diagnosis - A diagnosis within the scope of practice for aregistered dietitian (RD) to diagnose and treat as defined by the Academy ofNutrition and Dietetics.National Provider Identifier (NPI) – A system for uniquely identifying allProviders of health care services, supplies, and equipment.Nutritional Counseling – See Medical Nutrition Therapy.ProviderOne – Health Care Authority’s primary provider payment processingsystem.CPT codes and descriptions only are copyright 2019 American Medical Association.6 MEDICAL NUTRITION THERAPY BILLING GUIDE
ProviderOne Client ID- A system-assigned number that uniquely identifies asingle client within the ProviderOne system; the number consists of nine numericcharacters followed by WA. For example: 123456789WA.Registered Dietitian (RD) – A dietitian registered with the Academy of Nutritionand Dietetics and certified by the Washington State Department of Health (DOH).Women, Infant, and Children (WIC) Program - The United States Departmentof Agriculture Special Supplemental Nutrition Program for Women, Infants andChildren (WIC) administered by the Department of Health. Direct client servicesare delivered by contracted local providers. WIC provides nutrition screening,nutrition education, breastfeeding promotion, health and social service referrals,and nutritious foods to pregnant, breastfeeding and postpartum women, infants,and children through the end of the month they turn 5 years of age.To be eligible, WIC clients must have: A nutrition-related health risk; and Income at or below 185% of the Federal Poverty Level (FPL) or be enrolled inMedicaid, Food Stamps, or Temporary Assistance for Needy Families (TANF)programs.CPT codes and descriptions only are copyright 2019 American Medical Association.7 MEDICAL NUTRITION THERAPY BILLING GUIDE
About the ProgramWhat is the purpose of the medical nutrition therapyprogram?The purpose of the medical nutrition therapy program is to ensure that clientshave access to medically necessary outpatient medical nutrition therapy andassociated follow-ups when: Provided by a registered dietitian (RD) meeting the provider requirementslisted under WAC 182-555-0400. Provided to eligible clients who are 20 years of age and younger with areferral from a physician, physician’s assistant (PA), or an advanced registerednurse practitioner (ARNP).CPT codes and descriptions only are copyright 2019 American Medical Association.8 MEDICAL NUTRITION THERAPY BILLING GUIDE
Client EligibilityMost Apple Health clients are enrolled in an HCA-contracted managed careorganization (MCO). This means that Apple Health pays a monthly premium to anMCO for providing preventative, primary, specialty, and other health services toApple Health clients. Clients in managed care must see only providers who are intheir MCO’s provider network, unless prior authorized or to treat urgent oremergent care. See HCA’s Apple Health managed care page for further details.It is important to always check a client’s eligibility prior toproviding any services because it affects who will pay for theservices.Who is eligible for Medical Nutrition Therapy?Medical nutrition therapy is available to patients who are age 20 and youngerand referred to a registered dietitian (RD) by a: Physician Physician Assistant (PA) Advanced Registered Nurse Practitioner (ARNP).How do I verify a client’s eligibility?Check the client’s services card or follow the two-step process below to verifythat a client has Apple Health coverage for the date of service and that theclient’s benefit package covers the applicable service. This helps preventdelivering a service HCA will not pay for.Verifying eligibility is a two-step process:Step 1.Verify the patient’s eligibility for Apple Health. For detailedinstructions on verifying a patient’s eligibility for Apple Health,see the Client Eligibility, Benefit Packages, and Coverage Limitssection in HCA’s ProviderOne Billing and Resource Guide.If the patient is eligible for Apple Health, proceed to Step 2. Ifthe patient is not eligible, see the note box below.Step 2.Verify service coverage under the Apple Health client’sbenefit package. To determine if the requested service is acovered benefit under the Apple Health client’s benefit package,see HCA’s Program Benefit Packages and Scope of Serviceswebpage.CPT codes and descriptions only are copyright 2019 American Medical Association.9 MEDICAL NUTRITION THERAPY BILLING GUIDE
Note: Patients who are not Apple Health clients may submit an application forhealth care coverage in one of the following ways:1.By visiting the Washington Healthplanfinder’s website.2.By calling the Customer Support Center toll-free at: 855-WAFINDER(855-923-4633) or 855-627-9604 (TTY)3.By mailing the application to:Washington HealthplanfinderPO Box 946Olympia, WA 98507In-person application assistance is also available. To get information about inperson application assistance available in their area, people may visit theWashington Healthplanfinder’s website or call the Customer Support Center.Are clients enrolled in an HCA-contracted managedcare organization (MCO) eligible?Yes. Most Apple Health (Medicaid) clients are enrolled in one of HCA’s contractedmanaged care organizations (MCOs). For these clients, managed care enrollmentis displayed on the client benefit inquiry screen in ProviderOne.All medical services covered under an HCA-contracted MCO must be obtainedthrough the MCO’s contracted network. The MCO is responsible for: Payment of covered services Payment of services referred by a provider participating with the plan to anoutside providerNote: A client’s enrollment can change monthly. Providers whoare not contracted with the MCO must receive approval fromboth the MCO and the client’s primary care provider (PCP) priorto serving a managed care client.Send claims to the client’s MCO for payment. Call the client’s MCO to discusspayment prior to providing the service. Providers may bill clients only in verylimited situations as described in WAC 182-502-0160.Note: To prevent billing denials, check the client’s eligibility priorto scheduling services and at the time of the service, and makesure proper authorization or referral is obtained from the HCAcontracted MCO, if appropriate. See HCA’s ProviderOne Billingand Resource Guide for instructions on how to verify a client’seligibility.CPT codes and descriptions only are copyright 2019 American Medical Association.10 MEDICAL NUTRITION THERAPY BILLING GUIDE
Managed care enrollmentApple Health (Medicaid) places clients into an HCA-contracted MCO the samemonth they are determined eligible for managed care as a new or renewingclient. This eliminates a person being placed temporarily in FFS while they arewaiting to be enrolled in an MCO or reconnected with a prior MCO. Thisenrollment policy also applies to clients in FFS who have a change in the programthey are eligible for. However, some clients may still start their first month ofeligibility in the FFS program because their qualification for MC enrollment is notestablished until the month following their Medicaid eligibility determination.New clients are those initially applying for benefits or those with changes in theirexisting eligibility program that consequently make them eligible for AppleHealth managed care. Renewing clients are those who have been enrolled withan MCO but have had a break in enrollment and have subsequently renewedtheir eligibility.Checking eligibility Providers must check eligibility and know when a client is enrolled and withwhich MCO. For help with enrolling, clients can refer to the WashingtonHealthplanfinder’s Get Help Enrolling page. MCOs have retroactive authorization and notification policies in place. Theprovider must know the MCO’s requirements and be compliant with theMCO’s policies.Clients have a variety of options to change their plan: Available to clients with a Washington Healthplanfinder account:Go to Washington HealthPlanFinder website. Available to all Apple Health clients:oVisit the ProviderOne Client Portal website:oCall Apple Health Customer Service at 1-800-562-3022. The automatedsystem is available 24/7.oRequest a change online at ProviderOne Contact Us (this will generatean email to Apple Health Customer Service). Select the topic“Enroll/Change Health Plans.”For online information, direct clients to HCA’s Apple Health Managed Carewebpage.CPT codes and descriptions only are copyright 2019 American Medical Association.11 MEDICAL NUTRITION THERAPY BILLING GUIDE
Clients who are not enrolled in an HCA-contractedmanaged care plan for physical health servicesSome Medicaid clients do not meet the qualifications for managed careenrollment. These clients are eligible for services under the FFS Medicaidprogram. In this situation, each Integrated Managed Care (IMC) plan will haveBehavioral Health Services Only (BHSO) plans available for Apple Health clientswho are not in managed care. The BHSO covers only behavioral health treatmentfor those clients. Clients who are not enrolled in an HCA-contracted managedcare plan are automatically enrolled in a BHSO with the exception of AmericanIndian/Alaska Native clients. Some examples of populations that may be exemptfrom enrolling into a managed care plan are Medicare dual-eligible, AmericanIndian/Alaska Native, Adoption support and Foster Care alumni.Integrated managed careClients qualified for managed care enrollment and living in integrated managedcare (IMC) regions will receive all physical health services, mental health services,and substance use disorder treatment through their HCA-contracted managedcare organization (MCO).American Indian/Alaska Native (AI/AN) clients have twooptions for Apple Health coverage:-Apple Health Managed Care; or-Apple Health coverage without a managed care plan (alsoreferred to as fee-for-service [FFS])If a client does not choose an
CPT codes and descriptions only are copyright 2019 American Medical Association. 2 MEDICAL NUTRITION THERAPY BILLING GUIDE Disclaimer Every effort has been made to ensure this guide’s accuracy. If an actual or apparent conflict between this document and an HCA rule arises, HCA rules apply. Billing guides are updated on a regular basis.
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Consolidated Billing 3 Medicare Part B 3. SNF Billing Requirements 4. Billing Tips 5 Special Billing Situations 6 Readmission Within 30 Days 6 Benefits Exhaust 7 No Payment Billing 8 Expedited Review Results. 9 Noncovered Days 10 Other SNF Billing Situations 10. Resources 12. The American Hospital Association (the " AHA
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eCriteria applicable only to the following subtopics: medical nutrition therapy and chemotherapy; medical nutrition therapy and radiation treatment. fMedical nutrition therapy is provided by a registered dietitian nutritionist. gCriteria applicable only to the following subtopics: malnutrition screening tools; nutrition assessment tools. Figure 1.
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