MNT Billing Attestation (Time/Units & Referral)

Patient: [Patient name, MRN, DOB]

Date of Service: [Date]

Rendering Clinician: [Full name, credentials (RD/RDN), NPI, clinic/department]

Encounter Type: [in-person / telehealth] (If telehealth, include patient location/state at time of service: [Patient location, state])

Place of Service: [Clinic name / facility name / patient home]

(This is a billing attestation add-on for MNT encounters to support claims and audit defense. Do not duplicate clinical assessment content from the primary nutrition note.)

Referral / Order Attestation

Referring Clinician: [Name, credentials, NPI] (NPI is required for Medicare claims. If missing, include: "Required element missing—do not submit claim until completed.")

Referral Date: [Date order written/entered]

Referral Source: [internal order / external referral / other]

Order Location in Chart: [EHR order ID / scanned document name / fax date] (Include if available)

Referral Verified: [Yes / No] (If No: "Do not submit claim until referral/order is obtained.")

Covered Indication / Eligibility

Covered Indication: [Diabetes / Renal disease/CKD (specify stage if known) / Post-kidney transplant (include transplant date if known) / Other (specify)]

Exclusion Screen:

• Patient NOT on maintenance dialysis (for renal MNT): [Confirmed / Not confirmed / Unknown]
• NOT inpatient at time of service: [Confirmed / Not confirmed / Unknown]
• NO same-day DSMT billed to Medicare: [Confirmed / Not confirmed / Unknown]

(If any exclusion is not confirmed or unknown, note explicitly and verify eligibility before billing.)

Qualifying Diagnoses

• [ICD-10 code] — [Diagnosis name] (Source: [problem list / referring order / clinician note])

(Add additional diagnoses as applicable.)

Medical Necessity Statement: [1–2 sentences linking the qualifying diagnosis to the purpose and clinical focus of MNT]

Face-to-Face Time & Billing

Start Time / Stop Time: [Start time] / [Stop time]

Total Face-to-Face Minutes: [Integer minutes] (Excludes chart review and documentation time. If unknown: "Required element missing—do not submit claim until completed.")

Intended Billing Code(s): [97802 (initial individual) / 97803 (subsequent individual) / 97804 (group) / G0270 (additional hours—individual) / G0271 (additional hours—group)]

Units per Code: [Code] — [Number of units] (Include brief rationale if manually calculated)

(Add additional codes/units as applicable.)

Group Details: (Include only if billing group code 97804 or G0271)

• Group Size: [Number of participants]
• Attendance: [Full session / Partial — minutes attended: (specify)]
• Group Topic: [Brief topic]

Annual Hours Tracking

(Include this section when the payer has annual limits; omit entirely if not applicable.)

Benefit Year Basis: [Calendar year / Plan year]

MNT Minutes/Units Used Prior to Today: [Value] (If unknown: "Utilization unknown—verify prior to billing additional hours")

Minutes/Units Including Today: [Value]

Remaining Minutes/Units: [Value] (If known)

Additional Hours Justification

(Include this section ONLY when billing beyond the typical annual allowance using G0270/G0271; omit entirely if not applicable.)

Trigger for Additional Hours: [Change in diagnosis / Change in medical condition / Change in treatment regimen / Other (specify)]

Second Referral/Order: [Date], [Referring clinician name, credentials, NPI], [Order location in chart], [Additional hours authorized if specified]

Clinical Rationale:

• [Concise statement linking the qualifying change to the need for additional MNT]
• [Concise statement describing why added MNT is clinically required]

(Document the specific change event and why it necessitates additional nutrition intervention—do not merely state "additional time needed.")

Attestation & Signature

"I personally provided the MNT services described above and have documented face-to-face time and referral/order information accurately for billing purposes."

Electronic/Handwritten Signature: [Signature]

Signed Date/Time: [Date and time]

Printed Name & Credentials: [Name, credentials]

(If any portion was drafted by a scribe or automated tool, the rendering clinician must review and sign to authenticate.)