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 16 intensive core sessions of a Centers for Disease Control and Prevention (CDC) approved curriculum (The National Diabetes Prevention Program, or National DPP) that provides practical training in long-term dietary change, increased physical activity, and behavior change strategies for weight control. The sessions are furnished weekly over six months in a group-based, classroom-style setting or in a virtual distance learning setting. After completing the core sessions, six less intensive follow-up meetings furnished monthly over the next six months help ensure that the participants maintain healthy behaviors. Suppliers may offer and patients may attend more than 22 sessions, but Medicare will only pay for up to 22 MDPP sessions per eligible patient.

Access the below MDPP related information from this page.

• MDPP Overview
• Eligible Beneficiaries
• Supplier Enrollment
• Sessions and Reimbursement
• CY 2024 HCPCS Changes
• Billing
• 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
• 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
  • Hemoglobin A1c test with a value between 5.7 and 6.4%; or
  • Fasting plasma glucose of 110-125 mg/dL; or
  • 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

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

In the Calendar Year (CY) 2024 Physician Fee Schedule (PFS) published on November 16, 2023, Centers for Medicare & Medicaid Services (CMS) finalized that Medicare Diabetes Prevention Program (MDPP) suppliers may continue to offer the set of MDPP services virtually, using distance learning delivery, through December 31, 2027. As part of the final rule, CMS updated the MDPP payment structure with fee-for-service (FFS) payments for attendance while maintaining the weight loss performance payments.

As of CY 2024, the number of MDPP G-Codes has been reduced from 11 to 6. Suppliers must submit one of two new G-Codes (G9886 for in-person, G9887 for distance learning) when submitting claims for payment for MDPP core and core maintenance sessions to their MACs. CMS will allow beneficiaries to attend 22 sessions (alone or in combination with other codes, not to exceed 22 sessions in a 12-month timeframe).

Effective as of January 1, 2024. HCPC G codes have been reduced from 11 codes to 6.

Medicare pays up to 22 sessions billed with codes G9886 and G9887, combined, in a 12-month period: Months 1-6: 1 in-person or distance learning session every week (max 16 sessions)

Months 7-12: 1 in-person or distance learning session every month (max 6 sessions)

MDPP suppliers must submit claim for 5 percent weight loss (G9880) prior to submitting claims for the maintenance 5 percent weight loss from baseline in months 7-12 (G9888).

Note that the bridge payment does not count towards the 22 MDPP sessions payable in CY 2024

Effective January 1, 2024, every MDPP session delivered via distance learning (make-up or regular session) should use G9887 (attended 60-minute session via distance learning).

Given the CY 2024 payment schedule, which pays for attendance on a fee-for-service basis, you are encouraged to schedule make-up sessions on a day other than a regularly scheduled session to avoid claims being rejected or denied by your MAC.

CY 2024 HCPCS Changes

Claims with DOS on or after January 1, 2024, will be denied for the following G-codes:

• G9873 (attended 1 core session)
• G9874 (attended 4 core sessions)
• G9875 (attended 9 core sessions)
• G9876 (attended 2 core maintenance sessions, no weight loss, months 7-9)
• G9877 (attended 2 core maintenance sessions, no weight loss, months 10-12)
• G9878 (attended 2 core maintenance sessions, with 5% weight loss, months 7-9)
• G9879 (attended 2 core maintenance sessions, with 5% weight loss, months 10-12)
• G9882 (attended 2 ongoing maintenance sessions, months 13-15)
• G9883 (attended 2 ongoing maintenance sessions, months 16-18)
• G9884 (attended 2 ongoing maintenance sessions, months 19-21)
• G9885 (attended 2 ongoing maintenance sessions, months 22-24

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 increased payments annually

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

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

Billing

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.

CY 2025 the Virtual Modifier (VM) no longer necessary on claims with a DOS on or after January 1, 2024.

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

CY 2025 bridge payments are no longer available. CY 2024 and prior 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.