Provider Outreach and Education (POE) Advisory Group Minutes - March 10, 2015 - JE Part B

Medicare provides coverage of diabetes screening tests for beneficiaries at risk for diabetes or those diagnosed with pre-diabetes.

Access the below related information from this page.

• Diabetes Self-Management Training (DSMT)
• Medical Nutrition Therapy (MNT)
• Resources

DSMT

Coverage is provided for beneficiaries who have been recently diagnosed with diabetes, were determined to be at risk for complications from diabetes, or were previously diagnosed with diabetes before meeting Medicare eligibility requirements and have since become eligible for coverage under the Medicare Program when a certified provider who meets certain quality standards furnishes these services.

HCPCS Codes

• G0108 - Diabetes outpatient self-management training services, individual, per 30 minutes
• G0109 - Diabetes outpatient self-management training services, group session (two or more), per 30 minutes

Coverage Guidelines

Ten hours of initial DSMT during the first 12-month period are covered if the guidelines below are met:

• Beneficiary must be diagnosed with diabetes and determination is in medical records
• Physician or non-physician practitioner treating beneficiary must certify services are necessary
• Plan of care must be maintained in beneficiary's medical record and if individual training is needed, include reason for training as well
• Order must include:
  • Statement signed by physician indicating service is needed
  • Number of initial or follow-up hours ordered
  • Topics to be covered in training
  • Determination that beneficiary should receive individual or group training. If individual training is needed, the following conditions must be met.
    • No group session available within two months of date training is ordered;
    • Physician documents special needs, such as vision or hearing impairment, that may hinder effective participation in group training;
    • Additional insulin training is ordered

Two hours of follow-up training per year are covered if the guidelines below are met.

• Group training consists of 2-20 individuals who do not need to be Medicare beneficiaries
• Follow-up training is based on 12-month calendar year
• Follow-up training is furnished in increments of no less than one-half hour
• Physician or non-physician practitioner documents that beneficiary is diabetic

Accreditation

DSMT can be provided by providers who meet quality standards of CMS-approved national accrediting organizations such as the American Diabetes Association and Association of Diabetes Care & Education Specialists (ADCES).

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

Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) suppliers can be reimbursed for this training if they are enrolled with the A/B MAC and meet the accreditation standards.

In rural areas, an individual qualified as a Registered Dietician (RD) and as a Certified Diabetic Educator (CDE) and is certified by a CMS-approved organization, can furnish the training and is deemed to meet the multidisciplinary team requirement.

Registered Nurses (RNs) and pharmacists can furnish the training; however, they are not eligible for Medicare enrollment. He/she may work with another certified provider to bill on his/her behalf.

MNT

MNT is a therapeutic approach to treating medical conditions and symptoms using a nutrition and lifestyle assessment, counseling and monitoring progress. This is for beneficiaries who have diabetes or renal disease.

HCPCS Codes

• 97802 - Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with patient, each 15 minutes (Note: Use code for initial visit only)
• 97803 - MNT; re-assessment and intervention, individual, face-to-face with patient, each 15 minutes
• 97804 - MNT; group (two or more individuals), each 30 minutes
• G0270 - MNT; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease), individual, face to face with the patient, each 15 minutes (Note: Use code when there is a change in beneficiary's condition)
• G0271 - MNT; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition, or treatment regimen (including additional hours needed for renal disease) group (two or more individuals), each 30 minutes (Note: Use code when there is a change in beneficiary's condition)

Coverage Guidelines

During the initial calendar year, three hours of MNT are covered. Two hours each calendar year are covered during subsequent years. Unused hours cannot be carried over to the next year. The coverage criteria are:

• Primary care physician or specialist coordinating care for the beneficiary must make a referral and indicate a diagnosis of diabetes, renal disease or receiving a kidney transplant within last 36 months
• RD or nutrition professional must provide services
• Number of hours covered in episode of care cannot be exceeded unless a second referral is received from treating physician
• Services may be provided in either a group or individual setting
• DSMT and MNT services can be provided within same time period and maximum number of hours allowed under each benefit are covered.
  • Only exception is that DSMT and MNT cannot be provided on same day to same beneficiary
• Every calendar year beneficiary must have new referral for follow-up hours
  • Referrals may only be made by treating physician

Resources

• CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 270.4.3 and 300
• CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Sections 300
• CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 18, Section 90
• CMS National Coverage Determination (NCD) 180.1 for MNT