When billing insurance for Medical Nutrition Therapy (MNT) services in Kalix, proper charting is essential. Not only does it support accurate claims submission, but it also ensures compliance with Medicare, Medicaid, and private insurer documentation standards.

This article outlines what to include in your chart notes to support billing for CPT codes 97802, 97803, and 97804, using either the SOAP or ADIME format. These requirements apply to initial and follow-up visits, whether the service is delivered in person or via telehealth.

For all insurance types, chart notes should include the following (bolded points are considered especially important):

Accurate visit details are foundational to insurance billing. This section should clearly identify who the service was provided to, when and where it occurred, and under what circumstances. These details help verify the legitimacy of the session and establish the context for the services rendered.

Kalix streamlines this step by auto-populating client demographics and appointment times, but it's important to double-check for completeness, especially when billing insurance.

This section captures the client's own words and perspective—why they came to see you, what concerns they have, and how they perceive their current nutrition-related health. It helps build rapport while providing valuable insight into motivation and potential barriers. Documenting this information is essential for understanding the client's context and setting the stage for individualized care planning.

Information to include:

Objective data offers measurable evidence to support your assessment and plan. This includes anthropometric values, lab results, clinical history, and observations that inform your evaluation. Together with the subjective section, it forms a full picture of the client’s current status and risk factors, which is crucial for documenting medical necessity and determining appropriate interventions.

Information to include:

The nutrition diagnosis outlines the specific nutrition-related problem you are addressing. Using the PES (Problem, Etiology, Signs/Symptoms) format ensures that your reasoning is clear and supports billing requirements. It also helps differentiate between the medical diagnosis and the nutrition diagnosis, which is key for demonstrating your scope of practice while showing how your care ties directly to the client's condition.

Use a PES (Problem, Etiology, Signs/Symptoms) statement to document:

Example: Inadequate energy intake is related to poor appetite, as evidenced by 10% weight loss in 3 months and fatigue.

This is the most important part of your documentation when billing insurance:

Your chart note must clearly show that your interventions directly address the medical diagnosis (ICD-10 code) for which you are billing.

For example, if you are billing for a diagnosis of diabetes (E11.9), your intervention should include strategies to improve blood glucose control, such as carbohydrate education, label reading, or individualized meal planning.

Include:

This section should show how you will measure progress, follow up on goals, and adjust the plan as needed. Insurers want to see that nutrition services are ongoing and outcome-focused, making this section especially important for documenting the value of your care. You must show that your intervention addresses the ICD-10 diagnosis you are billing for.

Information to include:

When billing for time-based CPT codes, it's essential to document the total face-to-face time spent with the client. This not only justifies the units billed but also verifies that you met minimum time thresholds for reimbursement.

A unit represents a specific block of time associated with a CPT code:

You may bill multiple units for longer sessions (e.g., 45 minutes of MNT using 97803 = 3 units).

Your documentation must be signed, dated, and attributed to a qualified provider to be considered valid for insurance billing.

This satisfies documentation and compliance requirements without the need to manually add your signature to the text. Be sure to enable this feature when creating or finalizing your templates to streamline your workflow and ensure proper attestation.

Choose the best format for your workflow and compliance needs
Kalix offers multiple documentation formats to suit your charting style and support insurance billing requirements. Whether you prefer SOAP, ADIME, DAP, or a custom layout, Kalix makes it easy to create structured, complete, and compliant chart notes. You can also take advantage of built-in tools like auto-text fields, Quick Snippets, and required fields to improve accuracy, speed, and consistency across your notes.

You can document using:

If you're unsure whether your documentation supports insurance billing or if you'd like help customizing templates in Kalix, please contact us.

When charting in an EMR like Kalix (or any electronic medical record), it's crucial to link your nutrition interventions to the ICD-10 diagnosis code for which you are billing. In practice, this means your documentation should clearly show that the nutrition care you provided addresses the client's medical diagnosis (e.g., diabetes, chronic kidney disease, obesity). Doing so not only demonstrates medical necessity for your services but also supports insurance reimbursement and audit compliance. This guide will explain why this linkage matters, how to document it in both SOAP and ADIME formats (common charting styles for dietitians), and what insurers like Medicare, Medicaid, and private payers expect to see.

Linking your nutrition intervention to the client's medical diagnosis (ICD-10 code) is essential for several reasons:

ICD-10 codes explain why the client needs nutrition therapy – they represent the condition being treated. By clearly tying your intervention to the diagnosis, you show that the service was medically necessary for that condition. This is key to getting paid and avoiding denials. For example, if you provide diet counseling for a client with diabetes, using the diabetes ICD-10 code (e.g., E11.9) on the claim and in your note demonstrates the medical necessity of MNT for diabetes. Insurers expect the documentation to support the diagnosis as the reason for the service.

Insurance payers require that billed services correspond to a documented diagnosis. Properly linking the CPT service code (e.g., 97802 for MNT) with the appropriate ICD-10 diagnosis code in your notes and claim increases the likelihood of reimbursement. In fact, dietitians must include relevant ICD-10 codes on claims (CMS-1500 Box 21) or the claim will be denied. However, listing the code on the claim isn’t enough – your chart note should clearly indicate that the nutrition intervention was for that diagnosis.

"If it's not documented, it didn't happen." Thorough charting that links the intervention to the diagnosis is part of complete documentation. It creates a clear record of the client's medical condition and how you addressed it. Make use of those fields and reference the diagnosis in your narrative. For example, Kalix has built-in ICD-10 code support, and you should document the client's diagnosis (by code and name) in your note to make the connection explicit.

In the event of an insurance audit, one of the first things reviewers check is whether your documentation shows medical necessity and accuracy of billing. They will verify that the services provided were appropriately documented for the diagnosis billed.

A Clear linkage between the intervention and the ICD-10 diagnosis can navigate challenges in medical audits. In contrast, if your notes don't mention the condition or make it unclear why the nutrition service was needed, you risk failed audits or reimbursement claw-backs. As a best practice, maintain detailed records that clearly document the medical necessity of the services provided– this means explicitly stating the client's diagnosis and how your intervention addressed it.

To effectively link charted interventions to ICD-10 codes, use these documentation best practices:

Early in your note (e.g., in the assessment or at the top of a SOAP note), list the client's relevant medical diagnosis with its ICD-10 code and description.

This makes it immediately clear which condition your nutrition intervention is targeting. Kalix's chart notes have a designated spot to record the ICD-10 code for the visit – be sure to fill this in.

In your assessment section, you can connect the dots between the medical diagnosis and the nutrition problem or risk.

Even if you use the Nutrition Care Process (NCP) terminology for a nutrition diagnosis (PES statement), you should still reference the underlying medical condition as context. Note: Nutrition Diagnosis Statements are not a requirement for insurance billing.

This is critical – when writing the plan or intervention section of your note, explicitly mention the medical condition as the reason for your intervention. Describe what you did for that specific diagnosis.

By naming the condition (diabetes) in the intervention description, you leave no doubt that the counseling was directed at that problem. If multiple diagnoses are addressed in one session, you might outline interventions for each (e.g., “for diabetes we did X; for CKD (N18.3) we also did Y”).

Both government and private insurers emphasize the importance of linking your interventions to the billing diagnosis. Here's what Medicare, Medicaid, and private insurance look for and require:

Medicare Part B covers Medical Nutrition Therapy (MNT) for certain diagnoses and has strict rules on documentation. Medicare will only reimburse MNT for diabetes, chronic kidney disease, or post-kidney transplant (within 36 months) with a physician referral.

The referral from the treating physician should include the ICD-10 diagnosis (e.g., "E11.9 – Type 2 diabetes”) and be kept on file. Your documentation should note the referral and diagnosis (for example, "Referred by Dr. Smith for MNT for diabetes").

Medicare requires the provider's referral as evidence that the client has that diagnosis and needs MNT. Always ensure the ICD-10 code on your claim matches the diagnosis on the referral and in your note – this alignment is crucial for compliance.

Chart notes for each session should reiterate the diagnosis and what you did for it. For instance, a Medicare audit for an MNT claim will check that if you billed 97802 with diagnosis E11.9, your note explicitly says the client has type 2 diabetes and details nutrition interventions for diabetes management. If you document a diet plan without mentioning diabetes, the auditor may decide the service wasn't clearly tied to the covered condition. Medicare’s own guidance emphasizes that documentation must support the medical necessity of the service for that diagnosis. One recommendation is to include the ICD-10 code and diagnosis in the note as part of demonstrating necessity.

In summary, for Medicare, always document the link to the diabetes or CKD diagnosis in your note, consistent with the referral. This will satisfy Medicare’s requirement that the service was for a covered condition and was medically necessary.

Medicaid coverage for nutrition services varies by state, but most state Medicaid programs that reimburse dietitian services similarly require documentation of the medical condition and necessity. Many states mirror Medicare’s approach, covering MNT for diabetes and CKD; some also cover obesity or other diagnoses, especially in children. No matter the state, a few general principles apply:

Medicaid plans (and Medicaid Managed Care organizations) often explicitly require documentation showing why the service was needed.

To fulfill this, always include the client’s diagnosis and how your intervention addresses that diagnosis. If prior authorization is required for MNT, part of that approval is often based on the documented diagnosis, so your chart note should reinforce it.

Many Medicaid programs require a physician's referral for MNT (just like Medicare). Ensure the referral lists the diagnosis and keep a copy. In your note, reference that referral/diagnosis. For instance: "Patient referred by PCP for nutrition counseling for obesity (ICD-10 E66.9)." This ties the medical provider's diagnosis to your session and shows you're working under the referral as required.

Some Medicaid plans cover obesity counseling or other preventative nutrition counseling under programs inspired by the Affordable Care Act. If you are billing obesity counseling (sometimes covered under preventive services), you might use ICD-10 Z71.3 (Dietary counseling) plus a BMI diagnosis code (Z68.xx) or the obesity code E66.9, as allowed. Even in these cases, document the weight-related diagnosis and interventions.

The bottom line for Medicaid is to know your state's rules, but universally, ensure your notes connect the service to the medical diagnosis. If audited by Medicaid or a managed care plan, they will look for the same things – that the "reason for the nutrition visit" (the diagnosis) is noted and that your intervention is appropriate for that reason.

Private insurers (commercial insurance plans) often offer broader coverage for nutritional counseling, including preventive services. However, they are just as stringent when it comes to documentation, and they frequently conduct audits for compliance. Here's what to keep in mind for private insurance:

Even if an insurer covers a wide range of diagnoses (or even allows Z codes for preventative visits), you still need to show medical necessity in the chart. Many private payers follow the rule that the claim must have an ICD-10 code and the chart must support it.

Private insurance audits look for proper coding and documentation, just like Medicare. They want to see compliance with medical necessity guidelines and proper use of codes. To avoid issues, always chart with the assumption that an auditor will read it. That means explicitly stating the condition and tying in the intervention. A tip from practice is to use phrases like “Nutrition counseling for [diagnosis]” or “MNT session focused on [diagnosis]" in your plan. Some dietitians even copy the diagnosis code onto their session note (e.g. in an EMR template that pulls the code in) to be extra clear.

Many private plans cover nutrition counseling for obesity or diet-related chronic disease under preventive services. If you see a client for weight management without another illness, you might be billing Z71.3 (dietary counseling) and a BMI code, rather than E66.9, depending on the insurer. In such cases, it's still important to document the context (e.g., "Nutrition counseling session for dietary guidance due to BMI 32 (Obesity, class I)").

While Z71.3 on its own denotes general counseling, pairing it with the documented BMI or obesity diagnosis in your note provides a complete picture that this was obesity-related counseling. Private payers will also expect lifestyle interventions to be documented (diet, exercise advice given) since that's the standard of care for obesity – ensure your intervention details align with the diagnosis so the care seems appropriate and necessary.

A common reason for denial is when the documentation doesn't support the diagnosis on the claim. For example, if you accidentally used a diabetes code on the claim but your note was all about kidney disease, the insurer may deny or at least question the claim. Double-check that you used the correct ICD-10 code and that your note matches it. It can help to quote the diagnosis in your note exactly as coded. For instance, write "type 2 diabetes mellitus without complications (E11.9)” if that's the code – this leaves no ambiguity.

Some private insurers have specific documentation policies. For example, they may require chart notes to be submitted for review after a certain number of visits. UnitedHealthcare, Blue Cross/Blue Shield, Aetna, etc., all reserve the right to audit notes. They will check that the diagnosis listed on the claim is evident in the chart note and that the intervention is appropriate to that diagnosis. Always err on the side of over-documenting the connection. It not only helps in audits but also communicates to any other providers reading your notes what you focused on.

If you can tick all the above, you've likely created a chart note that withstands insurer scrutiny and demonstrates the value and necessity of your service for that ICD-10 diagnosis. This will help ensure your claims get paid and you remain in compliance with insurance requirements.

The key takeaway for dietitians using Kalix or any EMR is to always connect the dots between the client’s medical diagnosis and your nutrition intervention in your charting. From the very start of your note to the plan, weave in the ICD-10 diagnosis description at the end so it's evident that your counseling or intervention was aimed at that condition.

By following SOAP or ADIME formats with an eye on linking to the ICD-10 code, you create documentation that justifies your services to payers. This not only facilitates smoother reimbursement but also protects you in the event of audits by Medicare, Medicaid, or private insurers. Remember, insurance companies need to see the story of “what you did" and “why you did it” – the ICD-10 code is the “why,” and your intervention is the "what.” Make that story crystal clear. As long as your notes clearly show that the nutrition care you provided is for the documented diagnosis, you'll meet compliance standards and, most importantly, ensure continuity of care for your client by communicating the context of your intervention.