ModifiedEmblemHealthPolicy RP20250025

Nutritional Counseling Services (Commercial and Medicaid)

Defines when and how EmblemHealth will reimburse nutritional counseling/medical nutrition therapy services for Commercial and Medicaid products, including eligible procedure and diagnosis codes and plan-specific limitations.

Policy Summary

PayerEmblemHealth

PolicyNutritional Counseling Services (Commercial and Medicaid)

Policy CodePolicy RP20250025

Change TypeNew policy effective date

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionEnsure nutritional counseling is furnished by a qualified provider and billed with an eligible procedure and diagnosis code to be considered for reimbursement.

SourceLink

POLICY UPDATE CHANGES

New Policy effective 1/01/2026

Commercial & Medicaidproduct lines covered

CPT/HCPCS & ICD-10coding sections present

Medicaid fee schedule reqMedicaid note

0403T (Medicaid)preventive code

20+ICD-10 codes referenced

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Coverage and Reimbursement Criteria

Reimbursement criteria overview

EmblemHealth will consider reimbursement when nutritional counseling is furnished by a qualified provider as a necessary therapeutic component in disease management and when specified policy requirements and benefit limitations are met.

Reimbursement is considered when nutritional counseling is furnished by a qualified provider as a necessary therapeutic component in disease management (policy statement).

Services must be consistent with the requirements outlined in this policy and any applicable benefit/frequency limitations in the member's Membership Agreement or Evidence of Coverage.

Code eligibility and Medicaid fee schedule requirement

Code reimbursement is contingent on being a covered benefit and, for Medicaid, being listed on the Medicaid fee schedule.

Procedure codes are eligible for reimbursement only if the service is a covered benefit under the member's plan.

For EmblemHealth Medicaid plans, CPT/HCPCS codes will be reimbursed only if they are found on the Medicaid fee schedule; codes not on the Medicaid fee schedule will be denied.

ICD-10 code references

Applicable ICD-10 codes referenced for claims coding and processing.

Use one of the diagnosis codes listed in the Allowable ICD-10 codes table when reporting eligible procedure codes.

The policy includes an extensive list of applicable ICD-10 codes (examples include E10.3543, E10.36, E11.3212 and many additional diabetes-related codes).

Coding and billing references

The document provides ICD-10 code mappings relevant to reimbursement of nutritional counseling services; no explicit additional coverage criteria are present in this mapping section.

The policy contains mappings and cross-references between diabetes-related ICD-10 codes and gastrointestinal/encounter codes (examples: mappings showing E11.37X1 = K58.9 and other mappings).

Additional mappings relate diagnosis codes to encounter and Z-codes (examples in the policy include mappings to Z71.3 and various Z68 weight/height codes).

Coding/billing mappings are informational for claims processing and should be used alongside the policy's coverage requirements.

These mapping entries provide coding/billing reference but do not by themselves create separate coverage criteria beyond the policy's stated reimbursement requirements.

Procedure and Diagnosis Codes

Eligible procedure codesCPT | HCPCS | mixedCovered

0403T	Preventive behavior change, intensive program of prevention of diabetes using a standardized diabetes prevention program curriculum, provided to individuals in a group setting, minimum 60 minutes, per day (cover for Medicaid only).
97802	Medical nutrition therapy; initial assessment and intervention, individual face-to-face with the patient, each 15 minutes.
97803	Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes.
97804	Medical nutrition therapy; group (2 or more individual(s) each 30 minutes.
98960	Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient.
98961	Education and training for patient self-management by a qualified, non-physician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; 2-4 patients.
98962	Education and training for patient self-management by a qualified, non-physician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; 5-8 patients.
99078	Physician or other qualified health care professional qualified by education, training, licensure/regulation (when applicable) educational services rendered to patients in a group setting (eg, prenatal, obesity, or diabetic instructions).
G0108	Diabetes outpatient self-management training services, individual, per 30 minutes (Medicaid Only).
G0109	Diabetes outpatient self-management training services, group session, (2 or more), per 30 minutes (Medicaid Only).

Sample ICD-10 codes from listICD-10

E10.3543	ICD-10 code listed in applicable codes
E10.36	ICD-10 code listed in applicable codes
E11.3212	ICD-10 code listed in applicable codes

Additional ICD-10 cross-referencesICD-10

E11.37X3	ICD-10 code appearing in reimbursement policy section
E13.3539	ICD-10 code appearing in reimbursement policy section

ICD-10 mappings (partial list)ICD-10

K58.9	ICD-10 code mapped in document
K59.00	ICD-10 code mapped in document
Z71.3	Encounter for dietary counseling and surveillance (appears in mappings)

Group size minimum for 0403T

Code0403T

SettingGroup setting (2 or more)

Minimum durationMinimum 60 minutes per day

Coverage noteCovered for Medicaid only

ICD-10 list completeness

ScopePartial ICD-10 list presented across document; many diabetes-related codes enumerated

Sample codes

Provider Billing Guidance and Actions

Denial Risk

Follow industry coding edits; risk of denial/recoupment

EmblemHealth follows coding edits based on industry sources (CPT®, AMA, specialty organizations, and CMS including NCCI and MUE), and uses industry-standard claims editing software; failure to follow appropriate coding/billing guidelines or current reimbursement policies may result in claim denial and/or recoupment.

Edits applied from CPT, AMA, specialty organizations, CMS (NCCI, MUE)
EmblemHealth applies the edits it determines appropriate when sources conflict
Claims editing performed using industry-standard software
Noncompliant coding/billing may lead to denial and/or recoupment

Note

Policy title

Reimbursement Policy: Nutritional Counseling Services (Commercial and Medicaid).

Definitions and Terms

Medical Nutrition Therapy

DefinitionMedical Nutrition Therapy involves assessment of an individual's overall nutritional status followed by an individualized course of treatment to prevent or treat medical illness.

ComponentsIncludes assessment and individualized treatment planning

ConsiderationsAccounts for food intake, physical activity, medical therapies (including medications), and individual preferences

Nutritional Counseling Services (Commercial and Medicaid) - Policy scope

Policy scopeReimbursement Policy: Nutritional Counseling Services applies to Commercial and Medicaid lines; outlines when services are considered reimbursable and notes benefit/frequency limitations.

Eligible procedure codesIncludes CPT/HCPCS codes such as 0403T (Medicaid), 97802–97804, 98960–98962, 99078, G0108/G0109 (Medicaid)

Policy Revision History

2026-01-01policy_effective_dateLatest

New policy established with an effective date of 01/01/2026.