Medical Nutrition Therapy for Patients with Non–Dialysis-Dependent Chronic Kidney Disease: Barriers and Solutions

Abstract

Continuing Professional Education (CPE) InformationThe Continuing Professional Education (CPE) quiz for this article is available for free to Academy members through the MyCDRGo app (available for iOS and Android devices) and through www.jandonline.org (click on “CPE” in the menu and then “Academy Journal CPE Articles”). Log in with your Academy of Nutrition and Dietetics or Commission on Dietetic Registration username and password, click “Journal Article Quiz” on the next page, then click the “Additional Journal CPE quizzes” button to view a list of available quizzes. Non-members may take CPE quizzes by sending a request to [email protected] There is a fee of $45 per quiz (includes quiz and copy of article) for non-member Journal CPE. CPE quizzes are valid for 1 year after the issue date in which the articles are published.Chronic kidney disease (CKD) currently affects approximately 15% of the US population or 30 million US adults,1Centers for Disease Control and Prevention. National chronic kidney disease fact sheet, 2017. https://www.cdc.gov/kidneydisease/pdf/kidney_factsheet.pdf. Updated 2018. Accessed March 6, 2018.Google Scholar but incidence is projected to increase over the next 2 decades due to the ongoing obesity epidemic and the aging of the US population.2Hoerger T.J. Simpson S.A. Yarnoff B.O. et al.The future burden of CKD in the United States: A simulation model for the CDC CKD initiative.Am J Kidney Dis. 2015; 65: 403-411Abstract Full Text Full Text PDF PubMed Scopus (182) Google Scholar Almost half of all US adults aged 65 years and older are predicted to develop CKD during their lifetime.2Hoerger T.J. Simpson S.A. Yarnoff B.O. et al.The future burden of CKD in the United States: A simulation model for the CDC CKD initiative.Am J Kidney Dis. 2015; 65: 403-411Abstract Full Text Full Text PDF PubMed Scopus (182) Google Scholar The economic impact of CKD is substantial. Despite the fact that end-stage renal disease (ESRD), the most severe stage of CKD requiring kidney transplant or dialysis, is experienced only 650,000 US persons, the Medicare costs alone exceed $33 billion annually.3US Renal Data System Annual Data Report 2013. Chapter 11. Costs of ESRD. www.usrds.org/2013/view/v2_11_aspx. Updated 2016. Accessed August 19, 2016.Google Scholar Health care costs for earlier stages of CKD, when dialysis or transplantation is not required, exceed those for other expensive chronic conditions such as stroke and cancer.4Small C. Kramer H.J. Griffin K.A. et al.Non-dialysis dependent chronic kidney disease is associated with high total and out-of-pocket healthcare expenditures.BMC Nephrol. 2017; 18 (3-016-0432-2)Crossref PubMed Scopus (15) Google Scholar Because health care costs increase more than twofold as CKD advances to more severe stages, slowing or preventing CKD progression will substantially reduce health care costs. The Continuing Professional Education (CPE) quiz for this article is available for free to Academy members through the MyCDRGo app (available for iOS and Android devices) and through www.jandonline.org (click on “CPE” in the menu and then “Academy Journal CPE Articles”). Log in with your Academy of Nutrition and Dietetics or Commission on Dietetic Registration username and password, click “Journal Article Quiz” on the next page, then click the “Additional Journal CPE quizzes” button to view a list of available quizzes. Non-members may take CPE quizzes by sending a request to [email protected] There is a fee of $45 per quiz (includes quiz and copy of article) for non-member Journal CPE. CPE quizzes are valid for 1 year after the issue date in which the articles are published. Nutrition management remains among the most important interventions for slowing CKD progression and delaying or preventing ESRD.5Kalantar-Zadeh K. Fouque D. Nutritional management of chronic kidney disease.N Engl J Med. 2018; 378: 584-585PubMed Google Scholar Healthy lifestyle habits and the maintenance of a healthy weight play a key role in preventing type 2 diabetes and hypertension, the two major causes of CKD.6Garrison R.J. Kannel W.B. Stokes 3rd, J. Castelli W.P. Incidence and precursors of hypertension in young adults: The Framingham Offspring Study.Prev Med. 1987; 16: 235-251Crossref PubMed Scopus (608) Google Scholar, 7Hu F.B. Manson J.E. Stampfer M.J. et al.Diet, lifestyle, and the risk of type 2 diabetes mellitus in women.N Engl J Med. 2001; 345: 790-797Crossref PubMed Scopus (2175) Google Scholar Once kidney disease is established, dietary modifications such as decreasing intake of animal protein, phosphorus additives, and salt and increasing intake of fresh fruits and vegetables may slow kidney disease progression. However, dietary modifications for slowing kidney disease progression require patient education and close monitoring due to risks of malnutrition and hyperkalemia. Medical nutrition therapy (MNT), the individualized nutrition assessment, care planning, and dietary education provided by a registered dietitian nutritionist (RDN), remains an effective intervention for slowing CKD progression and delaying or even preventing ESRD. In 2000, the Institute of Medicine recommended MNT to patients with several diseases, including diabetes mellitus and/or nondialysis-dependent CKD because evidence demonstrates that MNT improves clinical outcomes and could decrease costs of care.8Institute of Medicine. The role of nutrition in maintaining health in the Nation’s elderly, Washington, D.C. National Academy Press. 2000.Google Scholar Currently, Medicare Part B covers MNT for patients with nondialysis-dependent CKD with no cost sharing. Many state Medicaid programs and private insurers also offer coverage for MNT for CKD. Despite the benefits of MNT on CKD progression and potential reductions in cost of care, the overwhelming majority of adults with CKD never receive MNT and most adults with CKD remain poorly informed of how diet influences disease management and progression. Although research specific to underuse of MNT services by RDNs for patients with CKD remains scant, anecdotal reports, along with initial research on low utilization of diabetes self-management training (DSMT), have identified potential barriers that may also hold true for patients with CKD.9Siminerio L.M. Implementing diabetes self-management training programs: Breaking through the barriers in primary care.Endocrine Practice. 2006; 12: 124-130Abstract Full Text Full Text PDF PubMed Google Scholar, 10Balamurugan A. Rivera M. Jack Jr., L. Allen K. Morris S. Barriers to diabetes self-management education programs in underserved rural Arkansas: Implications for program evaluation.Prev Chronic Dis. 2006; 3: A15PubMed Google Scholar, 11Diabetes self-management education barrier study. https://www1.maine.gov/dhhs/mecdc/phdata/non-dhp-pdf-doc/diabetes-self-managment-education-barrier-study-september-.pdf. Accessed June 4, 2018.Google Scholar, 12Powell M.P. Glover S.H. Probst J.C. Laditka S.B. Barriers associated with the delivery of Medicare-reimbursed diabetes self-management education.Diabetes Educ. 2005; 31: 890-899Crossref PubMed Scopus (21) Google Scholar, 13Peyrot M. Rubin R.R. Access to diabetes self-management education.Diabetes Educ. 2008; 34: 90-97Crossref PubMed Scopus (35) Google Scholar, 14Eakin E.G. Bull S.S. Glasgow R.E. Mason M. Reaching those most in need: A review of diabetes self-management interventions in disadvantaged populations.Diabetes Metab Res Rev. 2002; 18: 26-35Crossref PubMed Scopus (105) Google Scholar These potential barriers for MNT services for patients with CKD include low awareness of benefits by patients and clinicians, lack of availability of services from RDNs who may perceive the process of Medicare enrollment/insurance credentialing and billing as being burdensome and complex, inconsistent coverage for MNT services for CKD by non-Medicare payers, and patient travel and time issues to receive the services. In this review, we examine how diet may influence CKD progression and the role of MNT to improve health outcomes. We also examine reasons for low use of MNT services provided by RDNs for patients with CKD and potential solutions for increasing MNT use. CKD is classified into five G stages based on the estimated glomerular filtration rate (eGFR) using the serum creatinine levels measured with any metabolic panel.15KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease.Kidney Intl Suppl. 2013; 3: 28Google Scholar CKD G stages 1 and 2 are present when eGFR levels are ≥60 mL/min/1.73 m2 in the presence of other kidney abnormalities such as increased urine albumin excretion, a marker of kidney disease. Stages G3 to G4 are present when eGFR is between 59 and 15 mL/min/1.73 m2 and stage G5, the most advanced stage, is present when the eGFR falls below 15 mL/min/1.73 m2 or when renal replacement therapy such as dialysis is required.15KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease.Kidney Intl Suppl. 2013; 3: 28Google Scholar The 3 albuminuria or A stages additionally stratify CKD, allowing for more accurate risk prediction when added to the G stages. The albuminuria stages are defined using albumin-creatinine ratio with levels <30 mg/g for A1, 30 to 299 mg/g for A2, and ≥300 mg/g for A3. For a person with CKD who has not yet progressed to kidney failure, diet is a modifiable factor that may be altered at low cost. Thus, nutrition management should be a first-line intervention. Many factors in a patient’s diet can influence CKD progression. For example, the Western diet is characterized by high intake of red meat, animal fat, and salt combined with low intake of fresh fruits and vegetables16Lin J. Fung T.T. Hu F.B. Curhan G.C. Association of dietary patterns with albuminuria and kidney function decline in older white women: A subgroup analysis from the Nurses' Health Study.Am J Kidney Dis. 2011; 57: 245-254Abstract Full Text Full Text PDF PubMed Scopus (201) Google Scholar and contains a high amount of highly processed foods and saturated and trans fats.17Odermatt A. The Western-style diet: A major risk factor for impaired kidney function and chronic kidney disease.Am J Physiol Renal Physiol. 2011; 301: F919-F931Crossref PubMed Scopus (156) Google Scholar Individuals with dietary patterns that reflect a typical Western diet are more likely to have moderate to severely increased levels of urine albumin excretion, and a rapid decline in eGFR.16Lin J. Fung T.T. Hu F.B. Curhan G.C. Association of dietary patterns with albuminuria and kidney function decline in older white women: A subgroup analysis from the Nurses' Health Study.Am J Kidney Dis. 2011; 57: 245-254Abstract Full Text Full Text PDF PubMed Scopus (201) Google Scholar In contrast, dietary patterns low in processed and red meats and rich in fruits and vegetables such as the Dietary Approaches to Stop Hypertension and the Mediterranean diets have been shown to reduce CKD incidence.18Khatri M. Moon Y.P. Scarmeas N. et al.The association between a Mediterranean-style diet and kidney function in the Northern Manhattan study cohort.Clin J Am Soc Nephrol. 2014; 9: 1868-1875Crossref PubMed Scopus (90) Google Scholar, 19Huang X. Jimenez-Moleon J.J. Lindholm B. et al.Mediterranean diet, kidney function, and mortality in men with CKD.Clin J Am Soc Nephrol. 2013; 8: 1548-1555Crossref PubMed Scopus (105) Google Scholar, 20Rebholz C.M. Crews D.C. Grams M.E. et al.DASH (Dietary Approaches to Stop Hypertension) diet and risk of subsequent kidney disease.Am J Kidney Dis. 2016; 68: 853-861Abstract Full Text Full Text PDF PubMed Scopus (131) Google Scholar, 21Jacobs Jr., D.R. Gross M.D. Steffen L. et al.The effects of dietary patterns on urinary albumin excretion: Results of the dietary approaches to stop hypertension (DASH) trial.Am J Kidney Dis. 2009; 53: 638-646Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar Because CKD incidence and progression are so strongly influenced by nutrition-related factors, individualized dietary counseling or MNT should routinely be part of the care plan so that patients can make better informed choices to maximize their long-term health. Nutrition interventions have demonstrated improvements in glucose and blood pressure control, slowing of CKD progression, and delaying need for dialysis.22National Kidney FoundationKDOQI clinical practice guideline for diabetes and CKD: 2012 update.Am J Kidney Dis. 2012; 60: 850-886Abstract Full Text Full Text PDF PubMed Scopus (945) Google Scholar, 23Klahr S. Levey A.S. Beck G.J. et al.The effects of dietary protein restriction and blood-pressure control on the progression of chronic renal disease. Modification of Diet in Renal Disease study group.N Engl J Med. 1994; 330: 877-884Crossref PubMed Scopus (2051) Google Scholar, 24Levey A.S. Greene T. Beck G.J. et al.Dietary protein restriction and the progression of chronic renal disease: What have all of the results of the MDRD study shown? Modification of Diet in Renal Disease study group.J Am Soc Nephrol. 1999; 10: 2426-2439Crossref PubMed Google Scholar, 25Kasiske B.L. Lakatua J.D. Ma J.Z. Louis T.A. A meta-analysis of the effects of dietary protein restriction on the rate of decline in renal function.Am J Kidney Dis. 1998; 31: 954-961Abstract Full Text Full Text PDF PubMed Scopus (348) Google Scholar, 26Palmer S.C. Maggo J.K. Campbell K.L. et al.Dietary interventions for adults with chronic kidney disease.Cochrane Database Syst Rev. 2017; 4CD011998PubMed Google Scholar, 27Rhee C.M. Ahmadi S.F. Kovesdy C.P. Kalantar-Zadeh K. Low-protein diet for conservative management of chronic kidney disease: A systematic review and meta-analysis of controlled trials.J Cachexia Sarcopenia Muscle. 2018; 9: 235-245Crossref PubMed Scopus (96) Google Scholar, 28de Waal D. Heaslip E. Callas P. Medical nutrition therapy for chronic kidney disease improves biomarkers and slows time to dialysis.J Ren Nutr. 2016; 26: 1-9Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar A US retrospective propensity analysis of more than 156,000 incident patients undergoing hemodialysis suggested an independent association between more than 12 months of RDN pre-hemodialysis CKD care and lower mortality during the first year of dialysis therapy.29Slinin Y. Guo H. Gilbertson D.T. et al.Prehemodialysis care by dietitians and first-year mortality after initiation of hemodialysis.Am J Kidney Dis. 2011; 58: 583-590Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar The Academy of Nutrition and Dietetics (Academy) defines MNT as “an evidence-based application of the nutrition care process.”30Academy of Nutrition and Dietetics. Definition of terms list. Updated June 2017. http://www.eatrightpro.org/resources/practice/quality-management/scope-of-practice. Accessed January 8, 2018.Google Scholar In addition, the Academy states that MNT may include nutrition assessment/reassessment, nutrition diagnosis, nutrition intervention, and nutrition monitoring and evaluation that typically results in the prevention, delay, or management of diseases and/or conditions.30Academy of Nutrition and Dietetics. Definition of terms list. Updated June 2017. http://www.eatrightpro.org/resources/practice/quality-management/scope-of-practice. Accessed January 8, 2018.Google Scholar Although dietary counseling may be provided to patients by primary care physicians, nephrologists, or nursing professionals, the counseling is often brief and only involves broad suggestions such as reducing salt or protein intake. In contrast, MNT includes an in-depth individualized nutrition assessment, as well as the design and application of a personalized nutrition intervention. MNT also includes periodic monitoring, evaluation, and reassessment of the interventions that are tailored to impede disease progression. Although the cost-effectiveness of MNT has not been examined in depth for CKD, MNT provided by a RDN has been shown to be cost-effective for managing diabetes and hypertension, especially among older adults, and can be cost-saving.31Sheils J.F. Rubin R. Stapleton D.C. The estimated costs and savings of medical nutrition therapy: The Medicare population.J Am Diet Assoc. 1999; 99: 428-435Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar, 32Pastors J.G. Warshaw H. Daly A. Franz M. Kulkarni K. The evidence for the effectiveness of medical nutrition therapy in diabetes management.Diabetes Care. 2002; 25: 608-613Crossref PubMed Scopus (286) Google Scholar, 33Franz M.J. Powers M.A. Leontos C. et al.The evidence for medical nutrition therapy for type 1 and type 2 diabetes in adults.J Am Diet Assoc. 2010; 110: 1852-1889Abstract Full Text Full Text PDF PubMed Google Scholar, 34Franz M.J. Splett P.L. Monk A. et al.Cost-effectiveness of medical nutrition therapy provided by dietitians for persons with non-insulin-dependent diabetes mellitus.J Am Diet Assoc. 1995; 95: 1018-1024Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar, 35Anderson J.M. Achievable cost saving and cost-effective thresholds for diabetes prevention lifestyle interventions in people aged 65 years and older: A single-payer perspective.J Acad Nutr Diet. 2012; 112: 1747-1754Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar, 36Riegel G.R. Ribeiro P.A.B. Rodrigues M.P. Zuchinali P. Moreira L.B. Efficacy of nutritional recommendations given by registered dietitians compared to other healthcare providers in reducing arterial blood pressure: Systematic review and meta-analysis.Clin Nutr. 2018; 37: 522-531Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar Medicare coverage of MNT for management of chronic medical conditions is relatively new. The Balanced Budget Act of 1997 required the Secretary of the Department of Health and Human Services to contract with the National Academy of Sciences to examine the expected costs and benefits of covering MNT services for Medicare beneficiaries.37Department of Health and Human Services, Centers for Medicare and Medicaid services. Medicare program; revisions to payment policies and five-year review of and adjustments to the relative value units under the physician fee schedule for calendar year 2002; final rule. https://www.gpo.gov/fdsys/pkg/FR-2001-11-01/pdf/01-27275.pdf Accessed January 14, 2018.Google Scholar In response to this request, the Institute of Medicine (IOM) published the report Role of Nutrition in Maintaining Health in the Nation’s Elderly in 2000.8Institute of Medicine. The role of nutrition in maintaining health in the Nation’s elderly, Washington, D.C. National Academy Press. 2000.Google Scholar This IOM report recommended MNT services for individuals with undernutrition, cardiovascular disease, diabetes mellitus, kidney disease, and osteoporosis. Congress decided to allow Medicare coverage of MNT services for persons with diabetes mellitus and CKD and tasked the Department of Health and Human Services with making recommendations to extend coverage to the other three chronic conditions mentioned in the IOM report. In 2001, Section 105 of the Medicare, Medicaid and SCHIP [State Children's Health Insurance Program] Benefits Improvement and Protection Act added MNT services as a Medicare benefit for persons with diabetes mellitus or nondialysis-dependent CKD and then required that “registered dietitians or nutrition professionals” be included as a Medicare provider group.38Centers for Medicare and Medicaid Services. National coverage determination for medical nutrition therapy (180.1). Publication No. 100-3. 2002:June 14, 2016. https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?ncdid=252&ver=1. Accessed June 4, 2018.Google Scholar Medicare contractors started paying the MNT Medicare claims January 1, 2002, for MNT services with an RDN for Medicare Part B enrollees diagnosed with diabetes, CKD, or who received a kidney transplant during the past 36 months with a physician referral.39Centers for Medicare & Medicaid Services. Your Medicare coverage. https://www.medicare.gov/coverage/nutrition-therapy-services.html. Updated 2015. Accessed May 1, 2015.Google Scholar Most private insurers cover services as provided by Medicare and also provide MNT coverage for persons with CKD or diabetes. During the first year that MNT is provided, Medicare patients are eligible for 3 hours of either face-to-face counseling or counseling via an interactive telecommunications system originating from a site located in a county outside of a Metropolitan Statistical Area or a rural Health Professional Shortage Area within a rural census tract.40Department of Health and Human Services. Telehealth services. https://www.cms.gov/Outreach-and-Education/Medicare-learning-network-MLN/MLNProducts/downloads/TelehealthSrvcsfctsht.pdf Accessed January 14, 2018.Google Scholar During subsequent years, patients are eligible for 2 hours of counseling every year. The treating physician must provide a referral for MNT and indicate a diagnosis of diabetes or nondialysis-dependent CKD (CKD G stages 3, 4, or 5). Nonphysician practitioners cannot make referrals for this service. The MNT benefits covered by Medicare are considered a stand-alone billable service. Additional hours of MNT services are available to Medicare patients when the treating physician determines there is a change in diagnosis or medical condition that requires dietary changes, but the physician must write a second referral for MNT within the same calendar year. For patients with diabetes and CKD, DSMT may also be provided along with MNT, but practitioners cannot bill for DSMT and MNT benefits delivered on the same day. DSMT and MNT are different benefits and require separate referrals from a physician. DSMT is more general and includes basic training on diabetes self-care behaviors primarily in group formats. The goal of DSMT is to increase patient knowledge of why and how to change behaviors. In contrast, MNT provides individualized nutrition therapy to control diabetes and prevent CKD progression and personalized behavior change plans that may include eating plans, exercise, and control of stress. The Affordable Care Act expanded access to preventive services for people receiving Medicare, including MNT, by eliminating cost sharing for these preventive services. Currently, MNT requires no out-of-pocket expenses for Medicare beneficiaries who meet eligibility for MNT services and similar MNT coverage is often available via Medicaid and private payers as well. Currently, MNT is recommended by the National Kidney Foundation and the Academy for all persons with CKD regardless of stage.22National Kidney FoundationKDOQI clinical practice guideline for diabetes and CKD: 2012 update.Am J Kidney Dis. 2012; 60: 850-886Abstract Full Text Full Text PDF PubMed Scopus (945) Google Scholar, 41National Kidney FoundationK/DOQI clinical practice guidelines for chronic kidney disease: Evaluation, classification and stratification.Am J Kidney Dis. 2002; 39: S46-S64Google Scholar, 42Academy of Nutrition and Dietetics chronic kidney disease (CKD) evidence-based nutrition practice guideline. 2010. http://www.andeal.org/vault/pq119.pdf. Accessed January 17, 2017.Google Scholar MNT is also recommended by the American Diabetes Association for all individuals with diabetes,43Evert A.B. Boucher J.L. Cypress M. et al.Nutrition therapy recommendations for the management of adults with diabetes.Diabetes Care. 2013; 36: 3821-3842Crossref PubMed Scopus (389) Google Scholar, 44Franz M.J. Powers M.A. Leontos C. et al.The evidence for medical nutrition therapy for type 1 and type 2 diabetes in adults.J Am Diet Assoc. 2010; 110: 1852-1889Abstract Full Text Full Text PDF PubMed Scopus (200) Google Scholar, 45Andrews R.C. Cooper A.R. Montgomery A.A. et al.Diet or diet plus physical activity versus usual care in patients with newly diagnosed type 2 diabetes: The early ACTID randomised controlled trial.Lancet. 2011; 378: 129-139Abstract Full Text Full Text PDF PubMed Scopus (211) Google Scholar the number-one cause of kidney disease in the United States. Unfortunately, the overwhelming majority of US patients with CKD are not meeting with RDNs until they develop kidney failure and start dialysis because dialysis units are mandated to provide MNT services to all patients with ESRD. Although few studies have examined MNT use, existing data suggest that only one out of 10 patients with CKD receive any MNT before initiating dialysis.29Slinin Y. Guo H. Gilbertson D.T. et al.Prehemodialysis care by dietitians and first-year mortality after initiation of hemodialysis.Am J Kidney Dis. 2011; 58: 583-590Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar In 2016, approximately 7,100 Medicare claims for new patient visits for the CKD MNT benefit were recorded in the entire United States despite the fact that almost 2.7 million Medicare beneficiaries aged 65 years and older have CKD.46RBRVS Data Manager online. American Medical Association. https://commerce.ama-assn.org/store/catalog/productDetail.jsp?product_id=prod280002&navAction=push. 2017. Accessed June 4, 2018.Google Scholar, 47US Renal Data SystemUSRDS 2013 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2013Google Scholar Although it is likely that adults with diabetes are receiving general dietary counseling from their primary care practitioners, they are not meeting with RDNs to receive more intensive and individualized support for dietary modification. More time spent with an RDN may improve outcomes for patients with CKD.48Steiber A.L. Leon J.B. Hand R.K. et al.Using a web-based nutrition algorithm in hemodialysis patients.J Ren Nutr. 2015; 25: 6-16Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Among adults with type 2 diabetes, the number of visits and time spent with RDNs correlate with improvements in glucose and blood pressure control.49Lemon C.C. Lacey K. Lohse B. Hubacher D.O. Klawitter B. Palta M. Outcomes monitoring of health, behavior, and quality of life after nutrition intervention in adults with type 2 diabetes.J Am Diet Assoc. 2004; 104: 1805-1815Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar The low use of MNT services for persons with CKD may in part be a function of the existing reimbursement rates and billing implementation challenges for these services. National payment rates by Medicare for MNT services for patients with nondialysis-dependent CKD range from $132 to $141/hour for an initial visit and $112 to $122/hour for follow-up visits. Group sessions, which may include 2 or more patients, are paid at $31 to $32/hour per patient.50Centers for Medicare and Medicaid Services. Physician fee schedule CY18. https://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx. Accessed March 20, 2018.Google Scholar Figure 1 shows the Current Procedural Terminology codes used to bill Medicare Part B for MNT services and Figure 2 shows the requirements for reimbursement. To bill Medicare Part B, MNT services must be provided by an RDN enrolled in the Medicare program. In the case that such services are billed through a physician office practice or hospital outpatient clinic, an RDN must reassign his/her benefits to the practice/clinic. Some health centers and practice settings may opt to simply not provide MNT because of low reimbursement for these services.Figure 1Healthcare Common Procedure Coding System (HCPCS)/Current Procedural TerminologyaCPT Copyright 2018 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. (CPT) codes for Medical Nutrition Therapy (MNT). All assessments must be face to face.HCPCS/CPT codeMNT code descriptor97802MNT; initial assessment and intervention, individual, face to face with the patient, each 15 min97803MNT; reassessment and intervention, individual, face to face with the patient, each 15 min97804MNT; group (2 or more individual(s)), each 30 minG0270MNT reassessment and subsequent intervention(s) for change in diagnosis, individual, each 15 minG0271MNT reassessment and subsequent intervention(s) for change in diagnosis, group (2 or more), each 30 mina CPT Copyright 2018 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Open table in a new tab Figure 2Provider and patient qualifications for Medicare billing for medical nutrition therapy.Provider qualificationPatient qualificationRegistered dietitian nutritionistType 1 or type 2 diabetes, or estimated glomerular filtration rate 13-50 mL/min and no use of dialysis or kidney transplantation within past 36 moMedicare provider statusCannot be inpatient stay in hospital or skilled nursing facilityUse of nationally recognized protocolsInternational Classification of Diseases version 10 codes indicating medical necessityHospital outpatient department or independent practice settingChange in diagnosis requiring dietary changes may be used to extend medical nutrition therapy services Open table in a new tab Another barrier for implementing MNT services is a current workforce gap in RDNs credentialed with Centers for Medicare and Medicaid Services to provide and bill for MNT. In a survey conducted by the Academy in 2013 on coding and billing practices of RDNs, only about half of RDNs (48.2%) providing MNT services in an ambulatory care setting indicated they were Medicare providers.51Parrott J.S. White J.V. Schofield M. Hand R.K. Gregoire M.B. Ayoob K.T. Pavlinac J. Lewis J.L. Smith K. Current coding practi