The New CMS Therapeutic Diet Order Ruling: What Does It Mean For You?

Registered dietitian nutritionists (RDNs) are now permitted to become privileged to order therapeutic diets* without the supervision of a physician or another practitioner in the hospital setting. The Centers for Medicare and Medicaid Services (CMS) issued a final rule last week that revises the process by which therapeutic diets may be ordered. The new rule is the latest in a series of initiatives stemming from President Obama’s Executive Order issued in 2011, put forth to identify regulations that are unnecessary or burdensome. CMS expects this rule to save up to $459 million annually in hospital costs.

What Does the Current Rule State?

Currently, the CMS rule states: "a dietitian may assess a patient’s nutritional needs and provide recommendations or consultations for patients, but the patient’s diet must be prescribed by the practitioner responsible for the patient’s care." This process of diet order entry often causes a delay in patients getting the appropriate nutrition services, whether the correct diet, oral supplements, or tube feeding formula. Time is often wasted as RDNs seek out a physician, physician assistant (PA) or nurse practitioner (NP) in order to write or co-sign nutrition orders.

What is Different in the New Ruling?

The new guideline — which was first proposed in February 2013, and will be effective July 11, 2014 — allows RDNs who are privileged by their hospital to independently order therapeutic diets and nutrition related lab tests** without requiring a co-signature by a physician, PA or NP. This ruling further enhances the role of RDNs as the recognized nutrition experts who provide timely, cost-effective and evidenced-based nutrition services. It permits RDNs to do what they are trained to do, while freeing up time for physicians and other practitioners to care for patients.

How Will This Affect RDNs?

By allowing RDNs to independently order diets, valuable time will be saved in the care and treatment of patients, allowing for more efficient, effective implementation of nutrition care plans. I can think of many instances when I had patients awaiting a diet advancement or oral supplement delivery who waited hours until the approving providers could sign my patient diet orders. I can only imagine that this will greatly enhance patient satisfaction and provide better patient care.

What Happens Now?

The new rule goes into effect on July 11, 2014. In order for RDNs to order diets and labs, they must be granted privileges by the hospital. A hospital privileges practitioners by evaluating an individual’s competence to perform specific tasks. The Academy is developing tools for RDNs related to the privileging process, including suggestions how to discuss this with medical staff, detailed processes and strategies for obtaining privileges, and model policies and procedures for privileging RDNs.

One final note: while this is a huge national step forward, it is important to closely review state licensure laws and other state regulations prior to implementation of this new rule, because some states codified limitations on the ability of practitioners to order therapeutic diets. The Academy will be providing an analysis of the impact of these in the near future.

For more information, check out the Academy's FAQ page.


  •  There is not presently a definition of therapeutic diet. CMS has previously adopted the Academy-approved "therapeutic diet" definition, and the Academy is planning to continue work with CMS on the adoption of this definition across the continuum of care.
  • Ordering privileges for laboratory tests are determined by hospitals and their medical staffs in accordance with state law as well as any other requirements and/or incentives that CMS or other insurers might have.
Alissa Rumsey
Alissa Rumsey, RD, CDN, CNSC, CSCS, is a registered dietitian and certified strength and conditioning specialist based in New York City. She runs Alissa Rumsey Nutrition and Wellness Consulting, specializing in diabetes, cardiovascular disease, weight management, and sports nutrition. She is active in local, state and national professional organizations, and is a spokesperson for the Academy of Nutrition and Dietetics.