to refers to services specifically related to the medical care that is being provided by the physician at the time of the encounter. While Medicare Part B does not specifically cover or exclude payment for nutrition services, because regional carriers have the discretion to reimburse for nutrition services which are deemed reasonable and medically necessary, there are widespread inconsistencies and reimbursement is frequently denied. For patients who are enrolled in Medicare Part C (Medicare + Choice) it is up to the individual plan as to whether or not nutrition service is a covered benefit.

Under Medicare Part B, in order to be covered as an incident to service, the service must be provided by the physician or an employee of the physician, physician group practice, ambulatory surgical clinic, ambulatory clinic, or rural health clinic. If the service is provided by an employee of the above providers, it must be directly supervised by the billing physician. A nutrition professional, such as a dietitian, providing nutrition services is not authorized to submit requests for payment separately. Since dietitians are rarely employees of physician practices or ambulatory clinics, the lack of specific coverage for outpatient nutrition services is a significant barrier to nutrition therapy.

In 1996, the U.S. Preventive Services Task Force (USPSTF, 1996) recommended that “clinicians who lack the time or skills to perform a complete dietary history, to address potential barriers to changes in eating habits, and to offer specific guidance on meal planning and food selection and preparation, should either have patients seen by other trained providers in the office or clinic or should refer patients to a registered dietitian or qualified nutritionist for further counseling.” However, O’Keefe and colleagues (1991) reported that less than 25 percent of physicians routinely referred patients to a dietitian and only 10 percent had a dietitian available for dietary counseling. Most physicians or physician groups do not have sufficient funding in administrative budgets, office space, or enough patients requiring nutrition therapy to support hiring a dietitian as part of their office staff.

As part of the Balanced Budget Act of 1997, reimbursement for diabetes self-management is now a covered benefit for Medicare beneficiaries (see chapter 6). Currently, the proposed regulations for diabetes self-management developed by the Health Care Financing Administration require that a registered dietitian and certified diabetes educator participate in the diabetes education program and that programs are accredited by the American Diabetes Association. Although the final regulations will not be released until early 2000, the proposed regulations include ten visits during the first year of diagnosis and one visit annually thereafter.

Medicare reimbursement for ambulatory care moves to a prospective



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