Medicare MNT and Dietitian Licensure

For a dietitian who wants to bill Medicare, the licensing question gets stricter. State practice law may let you see a client without a license, as in Texas, but Medicare's own rule for medical nutrition therapy (MNT) asks for a state license or certification wherever one exists. That single regulation often decides how many licenses a Medicare-billing dietitian needs.

What does Medicare cover as MNT?

Medicare Part B covers MNT for two conditions. The regulations define MNT services as "nutritional diagnostic, therapeutic, and counseling services provided by a registered dietitian or nutrition professional for the purpose of managing diabetes or a renal disease" (42 CFR 410.130). Renal disease means chronic renal insufficiency, end-stage renal disease when dialysis is not received, or the 36 months after a kidney transplant.

A physician must refer the patient, and only when the patient has been diagnosed with diabetes or renal disease, with documentation in the medical record (42 CFR 410.132(a) and (c)). MNT for renal disease is not covered for patients receiving maintenance dialysis paid under Medicare's dialysis benefit (410.132(b)(1)). Hours are coordinated with diabetes self-management training, with exceptions when a physician documents a change in diagnosis, condition or treatment.

Who may provide Medicare MNT?

"For Medicare Part B coverage of MNT, only a registered dietitian or nutrition professional may provide the services" (42 CFR 410.134). The regulation defines that person as someone who, on or after December 22, 2000:

1. Holds a bachelor's or higher degree from a regionally accredited US college or university (or a foreign equivalent), having completed an accredited program in nutrition or dietetics.
2. Has completed at least 900 hours of supervised dietetics practice under a registered dietitian or nutrition professional.
3. "Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed."

Two exceptions apply to the first two items. A dietitian or nutritionist licensed or certified in a state as of December 21, 2000 does not have to meet them. And a registered dietitian in good standing with the Commission on Dietetic Registration (CDR) "is deemed to have met" them (410.134(d)).

How do states without dietitian licensure fit in?

The regulation answers this directly: "In a State that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a 'registered dietitian' by the Commission on Dietetic Registration," or meets the degree and supervised practice requirements (410.134(c)).

California, Colorado, Virginia and Arizona do not license or certify dietitians. Michigan and New Jersey have statutes but are not granting licenses while their regulations are not in effect, according to the Academy of Nutrition and Dietetics. Whether Medicare treats Michigan and New Jersey as states that "provide for" licensure is a question to confirm with your Medicare contractor rather than assume.

Why does Texas need special attention?

Because its license protects a title, not practice. The Texas licensing agency says "individuals are not required to hold a Texas dietitian license to practice dietetics in Texas in-person or via telehealth." But Texas does provide for licensure, so the Medicare rule asks for a Texas license for MNT performed in Texas. A dietitian who would never need a Texas license for private-pay clients may need one for Medicare patients. New York, which certifies dietitians, raises the same point: Medicare accepts state certification, and New York offers one.

Which state counts for a telehealth visit?

The regulation says "the State in which the services are performed." For telehealth, CDR's guidance on state law is that dietitians follow the laws of the state "in which the patients/clients are physically located at the time of service." We read the two together and plan for a license in the patient's state; confirm billing details with your Medicare contractor, since Medicare's telehealth payment rules are set separately from these qualification rules. Our sister site follows Medicare telehealth through 2027.

How does licensure fit with Medicare enrollment?

A state license is a prerequisite, not the enrollment itself. After the license issues, you enroll with Medicare as a provider, which is a separate process. Our sister site, White Glove Credentialing, covers Medicare enrollment through PECOS. Plan the license first, since the qualification rule above asks for it.

What does this mean for a multi-state practice?

• List Medicare patients by state. Each state that issues a dietitian license or certification needs one for Medicare MNT there.
• Do not rely on title-only practice rules. Texas lets you practice without a license; Medicare MNT in Texas does not.
• Use CDR registration where the state issues nothing. In California, Colorado, Virginia and Arizona, your RD status meets the requirement. Keep it current: CDR says the credential "lapses on October 1" if the annual maintenance fee is not received.
• Check telehealth registrations with your contractor. Florida's telehealth registration authorizes practice, but the Medicare rule speaks of being "licensed or certified." Confirm before billing on a registration alone.

Our post on how many licenses a telehealth RDN needs includes a Medicare example.

Can we prepare the licenses Medicare requires?

Yes. We prepare each state license and track it; you review, sign, pay the board and submit. License by Endorsement is $599 per state and a Full State License Application is $749 per state. For several Medicare states, a Multi-State Telehealth Package covers three states for $1,499 or five for $2,299. Enrollment with Medicare is handled by our sister site. Check each state on the license index.