What is the best practice for provider organizations to construct 270 requests to check patient eligibility for medical nutrition therapy services, and for payers to construct the 271 responses with the appropriate level of specificity? This question is specific to CPT codes 97802, 97803, and 97804. The X12 Service Type Codes (ID 958) includes "E28" (Dietary/Nutritional Services); however, that one is not available for use in version 005010. Which Service Type Code that is allowed in HIPAA transactions is the best fit for those CPT codes? Is there any other widely supported way to query US commercial health plans for medical nutrition therapy eligibility? It seems that most do not support using EQ02 to check eligibility for specific CPT codes and will instead return a generic response for Service Type Code "30."
A provider organization consisting of Registered Dieticians (RD) wants to check eligibility using HIPAA 005010X279 270 transactions with a wide range of commercial health plans to see what benefits their patients have for medical nutrition therapy.
Using the current mandated version, 005010X279A1, it is with regret we share there is no way to request medical nutrition therapy services without the support of procedure codes.
It is strongly recommended that information sources that wish to reduce phone calls and provider workflow inefficiencies design and develop ways to accept procedure codes for highly needed services or benefits that would benefit their providers. Alternatively, it is similarly highly recommended that information sources use other information sent on the 270 to help determine what sort of benefit or service detail should be returned that may be beneficial to the providers. An example could include the information source using the provider identification within the information source’s system to determine what provider type or specialty is tied to the information receiver or provider identified on the 270, and tailor the benefit or service details to that provider’s type/specialty. The medical nutrition therapy services could be returned using procedure codes (such as CPT codes 97802, 97803, and 97804) appropriate to the identified provider, assuming these are included benefits or services per the contract tied to the member’s plan. It is also recommended that the Information Source provide information regarding the Service Type Codes that are available, and any support for Procedure Codes that may or may not be available.