Medicare Diabetes Prevention Program (MDPP) - JE Part B

The Medicare Diabetes Prevention Program expanded model is a structured intervention with the goal of preventing type 2 diabetes in individuals with an indication of prediabetes. The clinical intervention consists of a minimum of 16 intensive "core" sessions of a Centers for Disease Control (CDC)-approved and Prevention curriculum furnished over six months in a group-based, classroom-style setting that provides practical training in long-term dietary change, increased physical activity, and behavior change strategies for weight control.

After completing the core sessions, less intensive follow-up meetings furnished monthly help ensure that the participants maintain healthy behaviors. The primary goal of the expanded model is at least five percent weight loss by participants.

Access the below MDPP related information from this page.

• MDPP Overview
• Eligible Beneficiaries
• Supplier Enrollment
• Sessions and Reimbursement
• Billing
• HCPCS Codes
• Documentation
• Bridge Payment

MDPP Overview

2022 reduced from two-year program to one-year program

Valid claims under MDPP, must have both CDC and Medicare separate enrollment:

• Centers for Disease Control and Prevention (CDC) preliminary or full recognition
  • Supplier Fact Sheet and CDC website for more information
  • MDPP Medicare beneficiary eligibility data returned via HIPAA Eligibility Transaction System (HETS) on 271 response
    • Use data to determine if beneficiary meets criteria to receive MDPP
• Separate Medicare enrollment as MDPP supplier (Specialty D1)
  • Claims reject if not separately enrolled
  • Enrollment Fact Sheet and Checklist
• After CDC approved and Medicare enrolled; may see eligible pre-diabetic patients
  • Medicare Diabetes Prevention Program (MDPP) Expanded Model
  • Quick Reference Guide to Payment and Billing and Billing and Claims Fact Sheet
• Once per lifetime set of services per beneficiary
• Submit claims when beneficiary performance goal met
  • List HCPCS code with corresponding session date of service and coach’s National Provider Identifier (NPI)
  • HCPCS associated with performance payment (including non-payable codes) on same claim
  • Must include "82" in Block 19 or electronic Loop 2300 Segment REF01 (P4) and Segment REF02 (82) to identify MDPP services
  • Do not include codes for other non-MDPP services on same claim
• MDPP program questions? Contact mdpp@cms.hhs.gov
• MDPP billing and claims? Contact Noridian, Medicare Administrative Contractor (MAC)

Eligible Beneficiaries

All the following criteria must be met to be eligible for this one-time benefit.

• Enrolled in Medicare Part B
• Have a body mass index (BMI) of at least 25 (or at least 23 if self-identified as Asian)
  • At first core session, height and weight must be measured in person and used to calculate BMI
• Met one of the following three blood test requirements within the 12 months of first core session
  1. Hemoglobin A1c test with a value between 5.7 and 6.4%; or
  2. Fasting plasma glucose of 110-125 mg/dL; or
  3. Two-hour plasma glucose of 140-199 mg/dL (oral glucose tolerance test)
• Have no previous diagnosis of type 1 or type 2 diabetes (other than gestational diabetes)
  • If a beneficiary develops diabetes while receiving MDPP services, he/she may continue with program
• Does not have End Stage Renal Disease (ESRD)

Note: A physician's referral is not required

The Noridian Medicare Portal (NMP) offers the following MDPP details within the Eligibility inquiry results:

• MDPP Active Period
• MDPP Inactive Period
• MDPP Deductible Period
• MDPP Coinsurance Period

Supplier Enrollment

MDPP suppliers exclusively having a ‘D1' specialty type on the NPI record will only receive the following Eligibility details:

• Medicare Beneficiary Demographics
• Date of Death
• Unlawful Occurrences
• Medicare Part B Entitlement
• MDPP Coverage
• MDPP Financial Information
• End Stage Renal Disease (ESRD)
• Medicare Advantage Enrollment(s)
• Medicare as a Secondary Payer (MSP) Enrollment(s)

More information can be found on the MDPP Enrollment webpage.

Sessions and Reimbursement

Payment is tied to performance goals based on attendance and/or weight loss. Suppliers will receive payment for beneficiaries who attend at least two out of three-monthly sessions within a core or ongoing maintenance interval, given other payment requirements are satisfied.

MDPP providers must accept Medicare's payment as payment in full and cannot bill or collect any amount from the beneficiary.

CMS Expanded Model updates with increased payments from $35 to $175 (previously $26 to $165)

Core Sessions Months 0 - 6

• MDPP suppliers must offer a minimum of 16 sessions, offered at least a week apart
• Sessions are available to eligible beneficiaries regardless of weight loss and attendance
• MDPP suppliers must use a CDC-approved curriculum to guide sessions

5% weight loss is not required to receive payment

Core Maintenance Sessions Months 7 - 12

• MDPP suppliers must offer a minimum of six monthly sessions during the second six months
• Sessions are available to eligible beneficiaries regardless of weight loss and attendance
• MDPP suppliers must use a CDC-approved curriculum to guide sessions

Payments are made in two three-month intervals

Additional payment for 5% weight loss achieved months 0 - 12: (G9880)

Ongoing Maintenance Sessions Months 13 - 24

Second year maintenance no longer needed for new beneficiaries enrolled after January 1, 2022

• MDPP suppliers must offer monthly maintenance sessions
• Eligible beneficiaries who achieve and maintain weight loss and attendance goals have coverage for three-month intervals of monthly maintenance sessions for up to one year
  • Beneficiary must be weighed during in-person sessions
• MDPP suppliers must use topics from a CDC-approved curriculum to guide sessions. Session topics may be repeated.

Payments are made in four three-month intervals and only if the beneficiary attends two ongoing maintenance sessions and achieves 5% weight loss

Additional payment for 9% weight loss achieved months 0 - 24: (G9881)

Billing

MDPP HCPCS codes may be used only one time per eligible beneficiary (except for G9890 and G9891).

The initial session (G9873) or bridge payment (G9890) claim must be submitted before any other claims will be paid.

Use the non-payable G-code (G9891) to report attendance at sessions that are not associated with a performance goal. These codes should be listed on the same claim as the payable code with which they are associated (e.g., report G9891 for sessions 2 and 3 if G9874 for session 4 attendance is being reported).

MDPP suppliers should submit claims when a performance goal is met.

Each HCPCS G-code should be listed with the corresponding session date of service and rendering coach National Provider Identifier (NPI).

MDPP services and non-MDPP services must be billed on separate claim forms; however, multiple MDPP services for the same beneficiary may be submitted on the same claim.

The VM modifier (virtual make-up session), should be billed with any G-code that is associated with a session that was furnished as a virtual make-up session.

HCPCS Codes

• Core Sessions
• Core Maintenance Sessions
• Ongoing Maintenance Sessions
• Additional Codes

Core Sessions

Core Maintenance Sessions

Ongoing Maintenance Sessions

Four HCPCS below not recognized for new enrollees for 2022; still current for 2021 and prior

Additional Codes

Documentation

MDPP suppliers must maintain the following electronic or paper records for 10 years following the last day of an MDPP beneficiary's receipt of services (certain circumstances may require extension):

• Upon first session, suppliers must record:
  • MDPP supplier name, CDC DPRP number, and NPI
  • Beneficiary information including but not limited to: beneficiary name, Medicare number and age
  • Evidence that each beneficiary meets eligibility requirements
• Upon each additional MDPP session, suppliers must record:
  • Session type (core, core maintenance, or ongoing maintenance); regularly scheduled or make-up (if a make-up, whether virtual or in-person); NPI of coach furnishing session; date and place of session; curriculum topic; and each beneficiary's weight (only required for regularly scheduled sessions)
• When applicable, MDPP supplier records must indicate when an MDPP beneficiary has:
  • Attended core sessions
  • Achieved 5% weight loss
  • Attended core maintenance sessions, has achieved or maintained minimum weight loss, or both
  • Attended two ongoing maintenance sessions and maintained required minimum weight loss
  • Achieved at least 9% weight loss
• MDPP suppliers must keep records of certain beneficiary engagement incentives provided to beneficiaries in compliance with 42 CFR 424.210

Bridge Payment

In cases where a beneficiary changes MDPP suppliers, CMS provides a one-time $25 bridge payment (G9890) to an MDPP supplier for furnishing its first session to an MDPP beneficiary who has previously received MDPP services from a different MDPP supplier. This is only allowed if the organization did not furnish the original core session to that beneficiary. More than one supplier may claim a bridge payment for the same beneficiary.

The bridge payment accounts for the financial risk a subsequent MDPP supplier takes on by furnishing services to a beneficiary changing MDPP suppliers during the MDPP services period and helps ensure beneficiary freedom of choice. MDPP suppliers may need to obtain a beneficiary's MDPP record from the previous MDPP supplier as part of the billing supplier's documentation to demonstrate that the attendance and weight loss, performance goals, if applicable, were achieved.