97802
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.53
Facility
$26.39
Non-Facility
$36.74
Documentation Required
- Documentation of the diagnosis/indication prompting nutritional counseling (e.g., obesity, overweight with documented BMI and specified CVD risk factors, diabetes mellitus, eating disorder, gastrointestinal disorder, hypertension, kidney disease, seizures, COPD, ESRD).
- Documentation of BMI or appropriate BMI/BMI-for-age percentiles (adult BMI values and pediatric percentiles) when used to support coverage (Z68.* codes referenced).
- Documentation of presence of cardiovascular disease risk factors when invoking coverage for overweight adults (explicitly: hypertension, dyslipidemia, impaired fasting glucose, or metabolic syndrome).
- For ESRD-related services: documentation that services included monitoring for adequacy of nutrition, assessment of growth and development, counseling of parents (for pediatric patients), and documentation of the number of face-to-face physician visits per month as required by the specific CPT code descriptor.
Key Coverage Criteria
- Medical nutrition therapy/nutritional counseling for chronic disease states: kidney disease.
- Nutritional counseling as a medically necessary preventive service for children who are obese.
- Nutritional counseling as a medically necessary preventive service for adults who are obese.
- Nutritional counseling for adults who are overweight (BMI > 25.0 kg/m2) and have other cardiovascular disease risk factors (hypertension, dyslipidemia, impaired fasting glucose, or the metabolic syndrome).
- Medical nutrition therapy/nutritional counseling for chronic disease states where dietary adjustment has a therapeutic role (examples explicitly listed): diabetes mellitus.
- Medical nutrition therapy/nutritional counseling for chronic disease states: eating disorders.
3 Active Policies
CIGNA-A004 — Preventive Care Services - (A004)
AETNA-CPB-0039 — Weight Reduction Programs and Devices
AETNA-CPB-0049 — Nutritional Counseling
Related Codes
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