Documentation & Health Records Flashcards

Which CPT code is used for the initial individual Medicare Part B medical nutrition therapy assessment and intervention, billed per 15 minutes?

Answer: 97802

97802 covers the initial individual MNT encounter in 15-minute units.

Medicare Part B covers medical nutrition therapy by a registered dietitian for which diagnoses?

Answer: Diabetes and non-dialysis chronic kidney disease, including post-kidney transplant

The Medicare MNT benefit is limited to diabetes, non-dialysis renal disease, and the post-kidney-transplant period.

How many hours of MNT does Medicare cover in the first calendar year of referral, without a new referral for changes?

Answer: 3 hours

Medicare covers 3 hours in the first year and 2 hours in each later year.

Under the ASPEN/Academy consensus, at least how many of the six characteristics must be documented to support a malnutrition diagnosis?

Answer: Two

At least two of the six characteristics (intake, weight loss, fat loss, muscle loss, fluid accumulation, grip strength) are required.

A dietitian identifies malnutrition, but the hospital can't code it for reimbursement. What is the most likely missing step?

Answer: The attending provider did not document or agree with the diagnosis in the record

Coders assign diagnosis codes from the provider's documentation, so the physician or NPP must document the malnutrition diagnosis.

Which HIPAA principle limits the protected health information a dietitian shares with a meal-delivery vendor to only what's needed for the task?

Answer: Minimum necessary standard

The minimum necessary standard limits uses and disclosures of PHI to what the purpose requires.

A dietitian remembers an important intake observation two days after the visit. How should it be documented?

Answer: Write it as a clearly labeled late entry with the current date and time, referencing the original date

Late entries must be labeled as such and carry the actual date and time they were written.