Nutritional Counseling Form

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Medical Policy Number: 10.01.VT205

Nutritional Counseling Corporate Medical Policy

File Name: Nutritional Counseling File Code: 10.01.VT205
Origination: 04/2002 Last Review: 12/2024 Next Review: 12/2025 Effective Date: 03/01/2025

Description/Summary

Nutritional counseling is individualized advice and guidance given to members at nutritional risk due to nutritional history, current dietary intake, medication use or chronic illness, about options and methods for improving nutritional status. A certified, registered, or licensed healthcare professional functioning within the scope of his or her license provides this counseling.

Nutritional counseling is often required for members with conditions such as diabetes, heart disease, kidney disease, obesity, eating disorders, or other nutrition related conditions.

Nutritional counseling begins with assessing the person’s overall nutritional status, followed by an individualized prescription for treatment. The dietitian or health professional takes into account a person’s food intake, physical activity, course of any medical therapy including medications and other treatments, individual preferences, and other factors.

Nutritional counseling of individuals with eating disorders as part of a multidisciplinary approach to treatment, is supported by the American Psychological Association, the Academy for Eating Disorders, and the American Academy of Pediatrics.

A multidisciplinary, coordinated approach to treatment includes a medical clinician, mental health clinician and dietician/nutritionist who, preferably, all have specialized knowledge and training in eating disorders.

Unique to the Registered Dietitian (RD) is the qualification to provide Medical Nutrition Therapy (MNT). MNT is an essential component of comprehensive nutrition care. Disease or

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Medical Policy Number: 10.01.VT205

conditions may be prevented, delayed, or managed, and quality of life improved in individuals receiving MNT. During MNT intervention, RDs counsel individuals on behavioral and lifestyle changes that impact long-term eating habits and health. MNT is an evidenced- based application of the Nutrition Care Process including:

1. Performing a comprehensive nutrition assessment
2. Determining the nutrition diagnosis
3. Planning and implementing a nutrition intervention using evidence-based nutrition practice guidelines
4. Monitoring and evaluating an individual’s progress toward goals Nutrition Therapy (MNT)

5. Policy Coding Information Click the links below for attachments, coding tables & instructions. Attachment I- Procedural Coding Table & Instructions
   Policy Guidelines

   When a service may be considered medically necessary

   • Medical Nutrition Therapy may be medically necessary for individuals with chronic diseases in which dietary adjustment has a therapeutic role (eating disorders, metabolic syndrome, coronary artery disease, hyperlipidemia, chronic kidney disease, hypertension, prediabetes, and diabetes); OR

   • Medical Nutrition Therapy may be medically necessary for children or adults who are obese; OR

   • Medical Nutrition Therapy may be medically necessary for adults who are overweight AND have a chronic disease.

   There is no limit on the number of visits for nutritional counseling per member per plan year.
   Background

   Definitions

   Metabolic diseases are typically hereditary diseases or disorders that disrupt normal metabolism, the process of converting food to energy on a cellular level. Thousands of enzymes participating in numerous interdependent metabolic pathways carry out this process. Metabolic diseases affect the ability of the cell to perform critical biochemical reactions that involve the processing or transport of proteins (amino acids), carbohydrates (sugars and starches), or lipids

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Medical Policy Number: 10.01.VT205

(fatty acids).

Eating disorders are characterized by a persistent disturbance of eating that impairs health or psychosocial functioning. The disorders include anorexia nervosa, avoidant/restrictive food intake disorder, binge eating disorder, bulimia nervosa, pica, and rumination disorder.

Eating disorders exist on a continuum of severity and various stages of remission and the DSM-5 diagnostic criteria define levels of severity and levels of remission for anorexia nervosa, bulimia nervosa, and binge-eating disorder. Reference Resources

1. Vermont State Diabetes Mandate: 8 V.S.A. § 4089c. Diabetes treatment.

2. American Dietetic Association. Position of the American Dietetic Association: Nutrition intervention in the treatment of anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified (EDNOS). J Am Diet Assoc. 2001; 101(7):810-819 Related Policies

   Medical Food for Inherited Metabolic Disease (IMD) Document Precedence

   Blue Cross and Blue Shield of Vermont (BCBSVT) Medical Policies are developed to provide clinical guidance and are based on research of current medical literature and review of common medical practices in the treatment and diagnosis of disease. The applicable group/individual contract and member certificate language, or employer’s benefit plan if an ASO group, determines benefits that are in effect at the time of service. Since medical practices and knowledge are constantly evolving, BCBSVT reserves the right to review and revise its medical policies periodically. To the extent that there may be any conflict between medical policy and contract/employer benefit plan language, the member’s contract/employer benefit plan language takes precedence. Audit Information

   BCBSVT reserves the right to conduct audits on any provider and/or facility to ensure compliance with the guidelines stated in the medical policy. If an audit identifies instances of non-compliance with this medical policy, BCBSVT reserves the right to recoup all non- compliant payments.

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Medical Policy Number: 10.01.VT205

Administrative and Contractual Guidance Benefit Determination Guidance

Benefits are subject to all terms, limitations and conditions of the subscriber contract.

NEHP/ABNE members may have different benefits for services listed in this policy. To confirm benefits, please contact the customer service department at the member’s health plan.

Federal Employee Program (FEP): Members may have different benefits that apply. For further information please contact FEP customer service or refer to the FEP Service Benefit Plan Brochure. It is important to verify the member’s benefits prior to providing the service to determine if benefits are available or if there is a specific exclusion in the member’s benefit.

Coverage varies according to the member’s group or individual contract. Not all groups are required to follow the Vermont legislative mandates. Member Contract language takes precedence over medical policy when there is a conflict.

If the member receives benefits through an Administrative Services Only (ASO) group, benefits may vary or not apply. To verify benefit information, please refer to the member’s employer benefit plan documents or contact the customer service department. Language in the employer benefit plan documents takes precedence over medical policy when there is a conflict. Policy Implementation/Update information

04/2003 Removed specific diagnosis codes. Replaces all memos or previous policies related to nutritional counseling, including TVHP. Applies to TVHP and BCSVT 06/2003 Added specific billing codes 08/2003 Language changes to support certificate and clarify benefit 09/2005 Language changes to support certificate 09/2006 Reviewed with minor word changes only and addition of revenue code on attachment page 09/2007 Reviewed no changes made 11/2007 Reviewed by the CAC 08/2011 Policy written in new format. “Calendar Year” language changed “Plan Year”. CPT 97804 deleted as this is a group counseling code. Removed reference to BCBSVT policies. Removed State of Vermont Licensed Nutritionist from list of eligible providers as this is a non-existent category Coding reviewed and correct per Medical/Clinical Coder SAR.

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Medical Policy Number: 10.01.VT205

06/2015 Added definitions of specific eating disorders and metabolic disease. Related policy: Inherited metabolic disease added. Clarification of policy guidelines. HCPCS (G codes) for nutrition therapy. Eating disorders added to attachment II. 10/2017 Updated medical criteria around prior approval for additional visits. Updated related policies. Updated coding table to re-sequence ICD -10 CM table. 07/2018 Re-sequenced ICD-10-CM coding table. Removed F50.9 as a duplicate code in coding table added F50.82 [Avoidant/restrictive food intake disorder] new code to match medical necessity criteria as an eligible diagnosis. Removed Coding Information Section. 07/2019 Reviewed added clarifying language around unspecified eating disorders and updated documentation requirement section. 02/2020 Added ICD-10-CM codes to table: F50.81 & F50.89 to coding table. 12/2021 Policy reviewed. No change to Policy Statement. Formatting changes. Background language changes. References updated. 12/2022 Policy reviewed. No change to Policy Statement. 12/2023 Updated policy to no longer require prior approval after three visits per plan year. Coding tables updated. 12/2024 Policy reviewed. Specific medical necessity criteria pertaining to eating disorders removed, leaning more general criteria pertaining to all diagnoses. Reference section updated.

Eligible providers

Qualified healthcare professionals practicing within the scope of their license(s).

Approved by BCBSVT Medical Directors

Tom Weigel, MD, MBA Vice President and Chief Medical Officer

Tammaji P. Kulkarni, MD Senior Medical Director

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Medical Policy Number: 10.01.VT205

Attachment I Procedural Coding Table & Instructions

Code Type Number Description Policy Instructions The following codes will be considered as medically necessary when applicable criteria have been met. CPT® 97802 Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes Prior Approval Not Required
CPT® 97803 Medical nutrition therapy; re- assessment and intervention, individual, face-to-face with the patient, each 15 minutes Prior Approval Not Required CPT 97804 Medical nutrition therapy; group (2 or more individual(s)), each 30 minutes Prior Approval Not Required HCPCS 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 Prior Approval Not Required HCPCS 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 Prior Approval Not Required HCPCS S9452 Nutrition classes, non-physician provider, per session Prior Approval Not Required Prior Approval Not Required HCPCS S9470 Nutritional counseling, dietitian visit Prior Approval Not Required REV 0942 Education/ Training