CPT code 97802 is the specific billing code used to identify an individual’s initial assessment and intervention for Medical Nutrition Therapy (MNT). This service is a face-to-face, evidence-based treatment provided by a qualified nutrition professional, focusing on managing specific diseases through a tailored nutrition plan. The code is structured as a time-based unit, representing each 15 minutes spent with the patient during this first visit. This article clarifies the circumstances under which Medicare covers this particular MNT service.
Medicare Coverage Status for Medical Nutrition Therapy
Medicare Part B covers outpatient medical services and supplies, and provides coverage for Medical Nutrition Therapy (MNT), including the initial assessment billed with CPT code 97802. MNT is a covered service only when furnished by a registered dietitian or a qualified nutrition professional who is enrolled as a Medicare provider.
The service must be provided by a professional who meets specific educational and credentialing requirements, often a Registered Dietitian Nutritionist (RDN). Coverage for MNT is generally exempt from the standard Part B deductible and coinsurance. If the provider accepts assignment, the patient typically owes nothing for the approved sessions.
Medicare Advantage Plans (Part C) are mandated to cover all services provided by Original Medicare Part A and Part B. Therefore, MNT services billed with CPT code 97802 are included in Medicare Advantage plan coverage. Beneficiaries enrolled in Medicare Advantage should confirm their plan’s specific network requirements, as the provider must be credentialed with that particular plan.
Specific Diagnosis Criteria for Eligibility
Coverage for CPT code 97802 is strictly limited to beneficiaries diagnosed with one of a few specific medical conditions, reflecting a targeted approach to disease management. The two primary diagnoses that qualify a patient for Medicare-covered MNT are diabetes and non-dialysis chronic kidney disease (CKD). Both Type 1 and Type 2 diabetes are qualifying conditions, and the MNT is intended to deliver nutritional counseling related to the impact of diet on managing blood sugar and other related complications.
For patients with chronic kidney disease, coverage is available for all stages of CKD prior to the point of needing dialysis. MNT is also covered for beneficiaries who have received a kidney transplant, but only for the first 36 months following the transplant procedure. The benefit does not cover MNT for patients with End-Stage Renal Disease (ESRD) who are already on dialysis, as nutrition services are bundled into the payment for the dialysis treatment itself.
A physician or other treating practitioner must formally diagnose the patient and provide a written referral for MNT services related to the qualifying condition. Medicare does not currently cover MNT for other conditions, such as obesity, hypertension, or dyslipidemia, unless one of the two qualifying diagnoses is also present. This restriction ensures that the covered benefit is focused on conditions where MNT has demonstrated the most significant clinical and cost-effective outcomes.
Annual Visit Limits and Referral Mandates
Medicare sets a clear limit on the amount of MNT services it will cover for an eligible beneficiary, measured in hours of face-to-face counseling per calendar year. In the initial calendar year, the standard allowance is three hours of individual or group counseling. In each subsequent calendar year, the standard allowance is two hours of covered MNT.
CPT code 97802 is used specifically for the initial assessment and intervention, billing for the first units of service in that initial three-hour allowance. Subsequent individual follow-up visits are billed using CPT code 97803, while group sessions use CPT code 97804. The three hours of initial MNT translates to twelve 15-minute units for the first year, and the two subsequent hours translate to eight 15-minute units.
A mandatory referral from the patient’s treating physician is required to initiate MNT coverage and must be renewed for the services to continue. This referral must clearly state the patient’s qualifying diagnosis (diabetes or renal disease) and affirm the medical necessity of the nutrition therapy. If a patient experiences a change in diagnosis, medical condition, or treatment regimen, the physician may provide a second referral in the same calendar year to request additional covered hours beyond the standard limit.