FWA Briefs

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Fighting Fraud in Medical Nutrition Therapy

  • by Steve Nesnidal, MD, CPC, AHFI
  • Apr 27, 2021, 12:30 PM

Nutrition can play a key role in many diseases. The role of nutrition in chronic disease management is especially crucial as it is a modifiable risk factor for many conditions such as chronic renal failure (CRF), diabetes mellitus (DM), obesity and coronary artery disease (CAD) risk factors.

Commercial payers who bear significant long-term healthcare utilization burdens due to the obesity and cardiovascular risk factors of their members may determine that Medical Nutrition Therapy (MNT) preventive coverage is a cost-effective policy approach for their members.   

CMS Guidelines for MNT

Medicare focuses instead on those chronic diseases known to impose a significant healthcare burden in this beneficiary population. The cost burden of chronic diseases with a significant nutritional component comes here from DM and CRF. The Centers for Medicare & Medicaid Services (CMS) published a National Coverage Determination (NCD) for Medical Nutrition Therapy (180.1) stating that approved providers can perform these MNT services for specific diagnoses within detailed utilization guidelines. Neither obesity nor CAD risk factors satisfy medical necessity diagnosis requirements for MNT per CMS.

Several Commercial payers have MNT medical policies, some of which outline specific diagnoses that satisfy medical necessity.  Some also set specific utilization limits.  Others are not specific regarding diagnosis nor do they set frequency limits of therapy. As already explained, medical necessity for MNT is driven by those disease states significant to that payer’s members.  As a result CMS medical necessity diagnoses differ from those established by Commercial (CM) or Medicaid (MA) policies. 

Though diagnoses don't translate among different payers, CMS utilization guidelines can serve as useful estimates of MNT utilization of CM and MA payers, when not specifically detailed in their policies. Current CMS MUE Provider limits include the following: 

  • CPT 97802 (MNT; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes) - Eight (8) units per DOS.
  • CPT 97803 (MNT; re-assessment, individual, face-to-face with the patient, each 15 minutes): Eight (8) units per DOS. 
  • CPT 97804 (MNT; group, each 30 minutes): Six (6) units per DOS.

Medicare MUE Practitioner Services limits are similarly set for these three codes. Several CM payers also mirror these same daily code limits.

MNT Fraud Risk

Aside from monitoring for excess of daily MUE, a search for MNT overutilization or fraud also requires the user to monitor the cumulative provider hours of MNT performed in a calendar year. CMS, for example, allows three hours of basic MNT coverage in the initial year of diagnosis. In each subsequent year, they allow two hours of basic coverage. From claims history, Context4 Healthcare’s FWA reports allow the user to isolate a provider’s total units of MNT submission in a given calendar year, to compare with the payer’s yearly set limits. This can reveal significant cumulative yearly excess of MNT services, even if the provider consistently remained below the daily utilization limit.

When our fraud, waste, and abuse (FWA) tools reveal a claim pattern wherein a provider routinely submits one or more hours of MNT on same DOS, we recommend a review of a sample of these supportive medical records. Although medical records may support this length of MNT in some encounters, 53 minutes of face-to-face time is the threshold we set for review (the minimum of time to support one hour).

In our experience, a consistent provider pattern of billing one continuous hour or more of any individual E/M service is worthy of review. When records support the number of MNT units submitted, the documentation mentions in appropriate detail the topics of nutritional therapy provided. Records should also clearly document that a credentialed nutrition professional performed the service face-to-face with that individual patient across the billed time interval. 

CMS CCI Provider Edits for these MNT codes are also useful as we search for patterns of FWA, for CM and MA as well as MC, as many payers use CMS CCI edits. Medicaid CCI edits can vary from Medicare CCI edits on occasion, but, overall, these edit files are very similar. On a given DOS, only one of the three MNT codes--97802, 97803 or 97804--should be billed. Initial MNT assessment (97802) should only be billed once per calendar year. On the same DOS as this initial service, it is never appropriate to also bill 97803 or 97804.

When our CCI edits identify more than one of these codes submitted by same provider for same member on same DOS, we always recommend an FWA medical documentation review, as audit of records will not yield support for both codes. Our FWA edits also raise other aberrant claim patterns. Resulting medical record review can also identify other FWA issues, such as group MNT billed as individual therapy.

Context4 Healthcare Guidelines for Customers

Payers that establish clear, specific coverage policies on MNT combat FWA by detailing their specific covered diagnoses and their allowable utilization guidelines. In absence of such a policy, payers must examine each claim for MNT services and perform a complex audit involving documentation to determine medical necessity. If there are no clear utilization guidelines for MNT services, payers may receive claims with questionable procedural frequencies. CMS clearly defines both covered diagnosis and utilization guidelines in their NCD. Context recommends that each CM and MA payer who decides an MNT policy is necessary for their Plan creates their own detailed MNT policy, to draw clear lines for providers. 

For the payer who has clearly defined their MNT policy, our FWA edits can effectively monitor for aberrant claim patterns on a given DOS. Our FWA reports (running total units of MNT codes by provider in calendar year) can also monitor for yearly MNT overutilization.  Also, our FWA  “Impossible Hours Report” can detect DOS where unreasonable total units of time-based codes were submitted by a provider or a provider group. Using a multifaceted approach, our tools monitor for FWA in Medical Nutrition Therapy. Contact us to discuss which of our suite of Context4 Healthcare tools will work best for your business.  

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