What CPT codes are used for medical nutrition therapy (MNT)?

MNT uses 97802 for initial assessment (15 minutes, individual), 97803 for reassessment (15 minutes, individual), and 97804 for group sessions (30 minutes). Bill in 15-minute increments for individual counseling. Medicare covers MNT for diabetes (type 1, 2, gestational) and renal disease (non-dialysis CKD, post-transplant) when provided by RD/RDN with physician referral.

What documentation is required for MNT billing?

Document: referral from physician with diagnosis, nutritional assessment (diet history, anthropometrics, labs), nutrition diagnosis using PES format (Problem, Etiology, Signs/Symptoms), intervention plan, goals (SMART format), patient understanding, and time spent. Include 24-hour recall, eating patterns, barriers to change, and specific education provided. Documentation must support medical necessity.

How many MNT visits does Medicare cover?

Medicare covers: first year - 3 hours total (1 hour initial assessment, 2 hours follow-up), subsequent years - 2 hours annually for diabetes and renal disease. Time can be split across multiple visits. Additional hours may be covered with documented change in diagnosis, medical condition, or treatment plan requiring significant diet modification. Physician referral required for each benefit period.

What is the ADIME documentation format for nutrition notes?

ADIME stands for: Assessment (anthropometric data, biochemical data, clinical findings, dietary intake, history), Diagnosis (nutrition problem using PES statement), Intervention (food/nutrient delivery, nutrition education, counseling, coordination of care), Monitoring/Evaluation (indicators to assess progress, criteria for resolution). This format demonstrates skilled dietitian services and supports billing.

Can MNT be billed with diabetes self-management education (DSMES)?

Yes, MNT and DSMES can be billed in the same benefit period but not on the same day for the same time. MNT focuses on individualized nutrition counseling, while DSMES covers broader diabetes self-management skills (glucose monitoring, medication, exercise). Document distinct services with separate time tracking. Coordination between RD and CDCES ensures comprehensive diabetes care.

Nutrition Counseling Template - Dietitian MNT Note

Nutrition — Counseling & Dietitian Note Template

Allied Health Nutrition Updated: 1/4/2026

The Nutrition Counseling Template is designed for Registered Dietitians (RD) and nutritionists providing medical nutrition therapy (MNT). This template documents 24-hour dietary recall, weight history, nutritional assessment, estimated energy needs, and specific dietary interventions. Supports billing for CPT codes 97802/97803. Ideal for weight management, diabetes education, and clinical nutrition.

Patient Information

Date: [Date]
Visit Type: Initial Assessment (97802) / Follow-up (97803)
Referring Diagnosis: [Diabetes, Obesity, HTN, CKD]

Anthro/Biochemical Data

Height: [Value] Weight: [Value] BMI: [Value]
Weight History: [Recent loss/gain]
Labs: A1c [X], Chol [X], Albumin [X], GFR [X]

Assessment (Subjective)

Dietary History / 24-Hour Recall:

Breakfast: [Content]
Lunch: [Content]
Dinner: [Content]
Snacks: [Content]
Beverages: [Content - sugary drinks?]

Eating Behaviors:

Frequency: [Meals per day]
Timing: [Skipping meals?]
Location: [Home vs Eating out]
Allergies/Intolerances: [Gluten, Dairy, etc.]
Supplements: [Vitamins, Protein]

Physical Activity: [Type, frequency, duration]

Diagnosis (Nutrition)

PES Statement:

[Problem] related to [Etiology] as evidenced by [Signs/Symptoms].

(Example: Excessive carbohydrate intake related to food knowledge deficit as evidenced by A1c of 9.2% and reported daily soda consumption.) Estimated Needs:

Calories: [X-Y] kcal/day
Protein: [X-Y] g/day
Fluid: [X-Y] mL/day

Intervention (Plan)

Nutrition Prescription:

Diet: [e.g., Carb Controlled, Cardiac, Renal, High Protein]

Education Provided:

Topics: [Label reading, Portion control, Meal planning, Carb counting]
Materials provided: [Handouts]
Patient understanding: Good / Fair / Poor

Goals (SMART):

1. [Goal 1 - e.g., Switch to diet soda]
2. [Goal 2 - e.g., Add 1 serving of vegetable to dinner]
3. [Goal 3 - e.g., Walk 15 mins post-dinner]

Monitoring & Evaluation

Follow-up Plan:

Return in [X] weeks.
Monitor: Weight, Food log, Blood glucose logs.

Nutrition — Counseling & Dietitian Note Template

Template

Patient Information

Anthro/Biochemical Data

Assessment (Subjective)

Diagnosis (Nutrition)

Intervention (Plan)

Monitoring & Evaluation

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