✅Documentation Standards for MNT Billing
This section outlines proper documentation standards to ensure accurate, compliant, and medically justified records for insurance billing and quality care.
👉 This section covers:
Proper Documentation Practices for Medical Nutrition Therapy (MNT) Billing
If you are not using Berry Street’s templates, please ensure your charting note includes all required fields. Every clinical record must accurately reflect the service provided and the level of care delivered on that specific date. Incomplete, cloned, or conflicting documentation may lead to denied reimbursement or payment clawbacks if an audit identifies inaccuracies.
Insurance plans may deny or reduce payment for services deemed not medically necessary, even if prior authorization was obtained. Documentation must clearly support the justification for each billed service and demonstrate medical necessity.
Required Information for Each Clinical Note
Include the following details in every patient record:
Patient legal name (first and last)
Patient date of birth
Rendering provider name, credentials, and individual NPI
Supervising provider (if applicable)
Date of service
Exact start and end times, and total appointment duration (in minutes)
⏱ MNT services are time-sensitive; accurate start/end times are required for compliance and billing.
Clinical Documentation
Use a SOAP or ADIME format—order and structure are flexible, but documentation must be clear, complete, and support medical necessity.
Treatment Plan
Maintain an updated treatment plan in the patient’s chart that includes:
History, examination, and diagnosis
Assessment and treatment recommendations
Date treatment began
Frequency and duration of sessions
Progress or regression toward goals
Supporting Documentation
Include all relevant materials related to the patient’s care, such as:
Labs, medical test results, and provider communications
Chart notes, billing records, and invoices
Educational materials (handouts, meal plans, food journals, etc.)
Accurate, complete documentation not only supports billing compliance—it strengthens continuity of care and demonstrates the clinical value of your work.
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