Does 97804 require prior authorization?

No, 97804 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 97804?

Medicare facility rate: $12.36. Non-facility rate: $17.03. Work RVU: 0.25.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

0.25

Facility

$12.36

Non-Facility

$17.03

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.

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.

CIGNA-A004 — Preventive Care Services - (A004)

AETNA-CPB-0039 — Weight Reduction Programs and Devices

AETNA-CPB-0049 — Nutritional Counseling

Ask Verity about documentation requirements, denial risks, or coverage in your state.