By Marianne Hutton, RD, CSR, CDE

Twenty million people in the U.S. or one in nine adults in America have chronic kidney disease (CKD). This is a growing public health concern. The number of people needing dialysis or transplant is expected to increase from 406,000 in 2000 to 651,000 in 2010. Total Medicare costs for CKD were $18.6 billion in 2004 ($16.3 billion was spent just providing dialysis).

Diet is the base of medical management and treatment of chronic kidney disease (CKD), diabetic kidney disease (DKD) and after a kidney transplant. Kidney disease can be prevented or it’s progression slowed by medical and nutritional changes. If you are a dialysis patient you have a renal dietitian at your clinic. But what about people who are not on renal replacement therapy and who would like some nutrition advice? According to the American Dietetic Association, referrals for medical nutrition therapy (MNT) are as easy as 1-2-3! Would you like to work with a nutrition expert to guide you on how to delay the progression of kidney disease but don’t know where to start? Let’s start at the beginning.

What is Medical Nutrition Therapy?
Medical nutrition therapy includes evidence based nutrition diagnostic, therapeutic and counseling services. It is designed to help you learn to eat right and take your nutrition related medications correctly. With a doctor’s signed referral, Medicare will cover 80 percent of the cost of MNT. Your diagnosis must be chronic kidney disease (not on dialysis) or diabetes. Medicare also covers for three years after a kidney transplant. (Of course, this coverage is after you pay your Part B deductible.) For MNT, non-dialysis kidney disease is defined as having a glomerular filtration rate (GFR) of 13-50 ml/min/1.73m2. This GFR range includes part of CKD Stage 3, Stage 4 and a small part of CKD Stage 5 (usually before needing dialysis or kidney transplant). Medicare beneficiaries may have from two to four sessions. The total time is three hours during the first year and eights hours total in the years that follow. Medicare will allow more time if your doctor requests so. You may also get MNT services in a group class or an individual treatment setting.

How Do I Get An Appointment with a Registered Dietitian (RD) for MNT?
1. Ask your doctor for a referral to a registered dietitian who specializes in kidney disease, diabetes and any other medical issues you may have indicating a need for “medical nutrition therapy” or MNT.

2. Your doctor will need to:
• include the covered diagnosis code(s) for your condition,
• send your most recent medical progress note and medication list,
• send your recent lab tests (blood and urine),
• sign a specific order for MNT in your medical chart, and
• give another MNT order if more services are needed.

3. You or your nurse can make the appointment with an RD at your local hospital outpatient clinic, an MD clinic if a dietitian is available or at a registered dietitian’s private practice office. Be sure to make a follow-up appointment after your first session.

What if I’m not covered by Medicare?
Most dietitians see a mix of Medicare, private insurance and self-pay patients. There are some cases in which a person may qualify for MNT services based on an existing health condition, such as diabetes or obesity. Some insurance carriers allow direct access to MNT services without the need for a physician referral. Many insurance plans cover diabetes education (group and individual). Check with your carrier to find out what your benefits are.

What else does Medicare Cover?
If you have diabetes, your doctor may say you need diabetes self-management training and education. Medicare will cover up to 10 hours of this training during your first year and two hours every year that follows. If more time for MNT is needed, you need another written referral. The doctor writes in your medical record why more services are important.

Most people with diabetes have what’s called “Type 2”. More than 50 percent of people on dialysis have some form of diabetes. A qualified dietitian knows how diabetes affects nutrition. With expert help, you can combine nutrition needs for CKD and diabetes. A dietitian knows how diabetes affects your body, knows about your medicines and how they work, as well as problems that can be avoided. They have the time and the expertise to coach you in making lifestyle changes that will make a difference. The diabetic management goals of controlling blood glucose, blood pressure and blood cholesterol and fat levels are even more important when associated with kidney problems.

In addition to 10 hours of diabetic self management training, Medicare will generally cover three hours of MNT for the first year and two hours every year thereafter. It will cover more hours if your doctor says you need them. Talk to your doctor if you think you qualify for this benefit.

To find a qualified registered dietitian in your area go to www.eatright.org and click on “Find a Nutrition Professional.”

If you or someone you know has diabetes, learn how to prevent kidney disease by attending an American Diabetes Association (ADA) Recognized Program. To locate an ADA recognized program near you, call 1-800-342-2383 or visit www.diabetes.org.

Marianne Hutton is a Registered Dietitian who is a Board Certified Specialist in Renal Nutrition and a Certified Diabetes Educator. She has a private practice in Santa Rosa, CA and her website is www.finelyfitnutrition.com.  

This article originally appeared in the July 2010 issue of aakpRENALIFE.

Posted 8/10/2010.

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