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Diabetic Self-Management Tool for Billing

DSMT and MNT complementary services. This means Medicare will cover both DSMT and MNT without decreasing either benefit as long as the referring physician determines that both are medically necessary. However, keep in mind that DSMT and MNT will not be allowed by Medicare when performed and billed for on the same date of service.

Diabetic Self-Management Training

Section 4105 of the BBA of 1997 permits Medicare coverage of the outpatient DSMT services when these services are furnished by a certified provider. Providers must be accredited as meeting approved quality standards, i.e., National Standards for Diabetes Self-Management Education Programs. CMS-approved national accreditation organizations include ADA, AADE and ADCES.

The performing provider must be enrolled as a Medicare Part B Provider. A treating physician must make a referral and indicate a diagnosis of diabetes or renal disease.

DSMT programs are credentialed with Medicare. Since DSMT is not a separately recognized provider type, providers cannot enroll in Medicare for the sole purpose of providing DSMT.

Health professionals are medical professional such as, health educators, registered dietitians, or nutrition professionals or other licensed practitioner or a team of such medical professionals, working under the direct supervision (as defined in 42CFR 410.32(b)(3)(ii)) of a physician as defined in this section.

A dietitian professional may not be the sole provider of the DSMT and MNT services; however, there is an exception for rural areas. In a rural area, an individual who is qualified as a registered dietitian and as a certified diabetic educator who is currently certified by an organization approved by CMS may furnish training and is deemed to meet the multidisciplinary team requirement. This exception is currently being waived for all dietitian professionals due to the public health emergency for COVID-19.

Registered dietitian or nutrition professional criteria

    • Minimum of Bachelor of Science degree in nutrition or dietetics
    • Completion of 900 hours of dietetics practice under supervision of registered dietitian or nutrition professional
    • Licensed or certified as a dietitian or nutrition professional by state in which services are performed (federal employees can be licensed or certified in any state)
    • Registered dietitian credential with the Commission on Dietetic Registration (CDR) is proof that education and experience requirements are met
    • Grandfathered dietitian, nutritional professionals licensed or certified as of 12/21/2000

Registered nurses and pharmacists can furnish the training; however, they are not eligible for Medicare enrollment. They work with another certified provider to bill on his/her behalf.

Cannot submit claims for DSMT services as “incident to” services.

Beneficiary Qualifications

    • Diabetes:
      • Diagnosed with Type 1, Type 2 or Gestational
      • Diabetes is a condition of abnormal glucose metabolism diagnosed using the following criteria:
        • FBS > 126 mg/dl on two different occasions
        • Two-hour post-glucose challenge > 200 mg/dl on two different occasions; or, a random glucose test over 200 mg/dl for a person with symptoms of uncontrolled diabetes
    • Renal:
      • Non-dialysis kidney disease
      • Post-kidney transplants

Billing Medicare

    • Hospital Outpatient Provider-based Clinic:
      • Form CMS-855B, Medicare Enrollment Application for Clinics/Group Practices and Certain Other Suppliers
    • Enroll in Medicare Part B, registered dieticians or nutrition professionals complete:
      • Form CMS-855I, Medicare Enrollment Application for Physicians and Non-Physician Practitioners
    • Registered dieticians or nutrition professionals reassign Medicare benefits to employer:
      • Form CMS-855R, Medicare Enrollment Application for Reassignment of Medicare Benefits
    • Electronic Enrollments Via:

Requirements for Coverage

Ordered by treating physician or qualified NPP managing beneficiary’s diabetic condition

    • Order/referral must include:
      • statement signed by physician or qualified NPP that service needed,
      • number of initial or follow-up hours of training ordered,
      • can order less than ten hours but not exceed ten hours,
      • topics to be covered in training, and
      • individual or group training determination.

Plan of care required to be documented in patient’s medical record

    • Original order by treating physician/NPP
      • Including any special conditions noted by physician
    • Must show services reasonable/medically necessary

When original order changed, order/referral must be

    • signed by treating physician/NPP and
    • maintained in patient’s file in DSMT program records.

Must be provided by a designated certified provider within accredited DSMT program.

Initial DSMT Training

    • 12-month period following initial certification
      • Beneficiary has not previously received initial or follow-up training (G0108 or G0109)
    • Furnished within continuous 12-month period
    • Does not exceed total of ten hours
      • Any combination of 30-minute increments
    • Training usually furnished in group setting
      • Not all need to be Medicare beneficiaries
    • One hour of individual training may be used for any part, including insulin training

Follow-Up DSMT Training

    • Based on 12-month calendar year after completion of full ten hours of initial training
    • No more than two hours of individual or group training per year
      • Furnished in increments of no less than 30 minutes
    • Group training consists of  2 to 20 individuals
      • Not all need to be Medicare beneficiaries
    • Documentation of diabetes diagnosis within patient’s medical record by treating physician or NPP

Follow-up training for subsequent years based on 12-month calendar year after completion of full ten hours of initial training

    • If beneficiary exhausts ten hours in initial year, eligible for follow-up training in next calendar year
    • If beneficiary does not exhaust ten hours in initial year, has 12 continuous months to exhaust initial training before two hours of follow-up training available

Individual DSMT Training

    • Allowable when:
      • No group session available within two months of date training ordered
      • Patient has special needs resulting from conditions such as severe vision, hearing or language limitations, or other such special conditions that will hinder effective participation in group training session
      • Physician orders additional insulin training
      • Need for individual training identified by physician or qualified NPP in referral

HCPCS/CPT

    • G0108: Diabetes outpatient self-management training services, individual, per 30 minutes
      • bill one unit per each 30-minute increment
    • G0109: Diabetes outpatient self-management training services, group session (two or more), per 30 minutes
      • bill one unit per each 30-minute increment

Diagnosis Coding 

Cost Sharing

    • Coinsurance applied
    • Deductible applied

Reimbursement

Nonparticipating Providers

    • Nonparticipating reduction applies
    • Limiting charge provision applies

Billing Tips

    • DSMT benefit is a stand-alone billable service separate from IPPE
    • DSMT and MNT benefits are allowed for same beneficiary in same year but not on same day
      • Requires separate referrals from physicians

Common Claim Denials

    • Beneficiary exceeded ten hour training limit
    • Physician or qualified NPP did not order training
      • No proof of order in medical record
    • Individual furnishing DSMT is not accredited by Medicare

References

Related Associations and Contact Information

American Diabetes Association (ADA)
2451 Crystal City Drive
Suite 800
Arlington, VA 22202
Phone: 800-342-2383

Association of Diabetes Care & Education Specialists (ADCES)
125 S. Wacker Dr.
Suite 600
Chicago, IL 60606
Phone: 800-338-3633

Promote Diabetes Awareness and Encourage Patients to take Advantage of the DSMT/MNT Programs

Published 1/27/2021

Diabetic Self-Management Tool for Billing
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