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3.6.2 Services/Benefits and Limitations
Only providers enrolled as licensed dietitians are eligible for reimbursement for nutrition therapy and counseling services.
Medical nutrition therapy (assessment, reassessment, and intervention) and medical nutrition counseling may be beneficial for treating, preventing, or minimizing effects of illness, injuries, or other impairments.
Medical nutrition counseling services are a benefits when all of the following criteria are met:
• The client eligible for CCP.
•The services are prescribed by a physician.
•Clinical documentation supports medical necessity and medical appropriateness.
•The services are performed by a Medicaid-enrolled dietitian licensed by the Texas State Board of Examiners of Dietitians.
•Federal financial participation is available.
Medical nutrition therapy (procedure codes 97802, 97803, and 97804) and nutrition counseling (procedure code S9470) may be considered beneficial for disease states for which dietary adjustment has a therapeutic role. The disease states include, but are not limited to, the following conditions:
•Cardiovascular disease
•Diabetes or alterations in blood glucose
•Hypertension
•Kidney disease
•Eating disorders
•Abnormal weight gain
•Gastrointestinal disorders
•Lack of normal weight gain
•Nutritional deficiencies
•Inherited metabolic disorders
Nutritional intervention for chronic fatigue syndrome, attention-deficit hyperactivity disorder, idiopathic environmental intolerances, and multiple food and chemical sensitivities is considered experimental and investigational and is not a benefit.
Medical nutrition counseling services for the diagnosis of obesity without a comorbid condition is not a benefit.
Providers are responsible for maintaining documentation to support medical necessity in the client's medical record.
Medical nutrition therapy (procedure codes 97802 and 97803) are limited to 4 units (1 unit = 15 minutes) per rolling year. Dietitian visits for nutrition counseling (procedure code S9470) are limited to 2 visits per rolling year. Medical nutrition group therapy (procedure code 97804) is not a benefit in the home setting and is limited to 8 units (1 unit = 30 minutes) per rolling year.
Procedure code S9470 is a less comprehensive service, and does not include an assessment or reassessment.
Procedure codes 97803 and 97804 will be denied as part of another service when submitted by any provider on the same date of service as procedure code 97802. Procedure code 97804 will be denied as part of another service when submitted by any provider on the same date of service as procedure code 97803. Procedure code S9470 will be denied as part of another service when submitted by any provider on the same date of service as procedure code 97802, 97803 or 97804.
A case manager, school counselor, or school nurse may refer a client for medical nutrition group therapy. Participation in medical nutrition group therapy is optional. A prescription from a physician is required, and informed consent must be obtained from the client's parent or guardian before rendering services. The medical documentation maintained in the client's medical record must include the following:
•Physician prescription
•Medical nutrition counseling service provided
•Goals or objectives for the group therapy
•Client participation
•Beginning and ending time of the group therapy session
Group therapy may be provided to a group of clients (minimum of two and maximum of ten) with the same condition. While medical nutrition group therapy must be led by a Medicaid-enrolled dietitian licensed by the Texas State Board of Examiners of Dietitians, other health-care providers may participate in the group sessions. The focus of the therapy is nutrition and health for chronic conditions such as the following:
•Acquired acanthosis nigricans
•Diabetes
•Dysmetabolic syndrome X
•Eating disorder
•Hyperlipidemia
•Other specified hypoglycemia
•Pure hypercholesterolemia
•Pure hyperglyceridemia
Medical nutrition group therapy must last at least 30 minutes and should include:
•An age-appropriate presentation on nutrition issues related to the chronic condition. The presentation may include information about prevention of disease exacerbation or complications and living with chronic illness. The presentation may also offer suggestions for making healthy food choices or changing ideas about food.
•A question and answer period.
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