Procedure code G0108 & G0109

Medicare provides coverage of diabetes self-management training (DSMT) services for beneficiaries who have been recently diagnosed with diabetes, 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

Procedure Codes and Descriptors

The following Healthcare Common Procedure Coding System (HCPCS) codes listed are used to report DSMT services

G0108 - Diabetes outpatient self-management training services, individual, per 30 minutes
G0109 - Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes

Note: For FQHCs, codes representing group sessions do not constitute a separate billable visit.

A qualified DSMT program includes the following services:

* Instructions in self-monitoring of blood glucose,
* Education about diet and exercise,
* An insulin treatment plan developed specifically for insulin dependent patients, and
* Motivation for patients to use the skills for self-management.

DSMT services are aimed toward individuals with Medicare who have recently been impacted in any of the following situations by diabetes:
*Problems controlling blood sugar,
*Beginning diabetes medication, or switching from oral diabetes medication to insulin,
*Diagnosed with eye disease related to diabetes,
*Lack of feeling in feet or other foot problems such as ulcers or deformities, or an amputation hasbeen performed,
*Treated in an emergency room or have stayed overnight in a hospital because of diabetes, or
Diagnosed with kidney disease related to diabetes.``

Coverage Information

Medicare provides coverage of DSMT services only if the treating physician or treating qualifiednon-physician practitioner managing the beneficiary’s diabetic condition certifies that DSMT services are needed. The referring physician or qualified non-physician practitioner must maintain a plan of care in the beneficiary’s medical record and documentation substantiating the need for training on an individual basis when group training is typically covered, if ordered. The order must also include a statement signed by the physician or qualified non-physician practitioner that the service is needed as well as thefollowing information:

*The number of initial or follow-up hours ordered (the physician can order less than 10 hours, but cannot exceed 10 hours of training),
*The topics to be covered in training (initial training hours can be used to pay for the full initial *training program or specific areas, such as nutrition or insulin training), and
A determination if the beneficiary should receive individual or group training.

Billing and Coding Guidelines

A – Coding

 The following HCPCS codes are used for DSMT:

• G0108 - Diabetes outpatient self-management training services, individual, per 30  minutes.

• G0109 - Diabetes outpatient self-management training services, group session (2 or  more), per 30 minutes.

The type of service for these codes is 1.

B - Initial Training

Medicare will cover initial training that meets the following conditions: y Is furnished to a beneficiary who has not previously received initial or followup training under HCPCS G0108 or G0109. 

** Is furnished within a continuous 12-month period. 

** Does not exceed a total of 10 hours for the initial training. The 10 hours of training can be done in any combination of 1/2 hour increments. They can be spread over the 12-month period or less.

** With the exception of 1 hour of individual training, training is usually furnished in a group setting who need not all be Medicare beneficiaries.

** The one hour of individual training may be used for any part of the training including insulin training.

** Is furnished in increments of no less than one-half hour. 

 Coding and Payment Requirements

 The provider bills for DSMT on the CMS Form 1450 or its electronic equivalent.

 The cost of the service is billed under revenue code 942 in FL 42 "Revenue  Code." The provider will report HCPCS codes G0108 or G0109 in FL 44  "HCPCS/Rates." The definition of the HCPCS code used should be entered in FL  43 "Description."

** Applicable Bill Types

 The appropriate bill types are 12x, 13x, 34x (can be billed if service is outside of  the treatment plan), 72x, 74x, 75x, 83x and 85x. 

• The following Medicare Part B provider healthcare entities and individual providers of a certified DSMT program can render the benefit. The individual providers can also bill on behalf of all the hours furnished in the program, even if they do not teach in the program; the hours cannot be subdivided in the billing process by multiple Medicare providers. The entities and individuals must first be billing Medicare for at least one other service and be receiving reimbursement. Payment is made under Medicare's modified physician fee-for-service payment schedule.

** Hospital outpatient departments, durable medical equipment companies, physician, non-physician practitioner, RD private practices, independent clinics, state and public health clinics, home health agencies, pharmacies and skilled nursing homes.

** Physicians (MDs, DOs), NPs, PAs, Clinical Nurse Specialists, clinical psychologists, LCSWs.

** An RD, RN, or RPh must be a program instructor, per the 2012 National Standards of DSME (required to achieve AADE accreditation or ADA recognition of DSMT program).

** RDs and nutrition professionals

** The certified diabetes educator credential (CDE) is not required, except if an RD or nutrition professional is the sole instructor in the DSMT program in a rural health clinic.

• Rural health clinics and federally qualified health centers:

** Only individual DSMT (G0108) is payable.

** RHCs are not paid separately under the Medicare fee-for-service methodology under Part B for DSMT claims. Instead, they are reimbursed by Medicare viathe reporting of the cost of the DSMT on the facility’s cost report and paid at Medicare’s current encounter all-inclusive rate.

** FQHCs as of Jan 1, 2016 are paid under the Prospective Payment System, but neither DSMT nor Medical Nutrition Therapy (MNT) are payable on same day as a medical visit.

• Initial DSMT:

** Does not exceed a total of 10 hours:

** At least 9 of the 10 must be in group unless the treating provider documents on the referral a special need or circumstance that limits group
learning; then all 10 hours may be individual. Examples of special needs include: extra insulin instruction language barrier, cognitive impairment, physical limitation, visual or hearing impairment. One of the 10 hours may be individual. (Does not apply to FQHCs/RHCs since only individual is covered. Check with your MAC about possible group coverage.)

** The 10 hours can be done in any combination of 0.5 hour increments, and can be spread over the first 12 consecutive month period or less (period starts with the date of the first visit and not the date on the referral).

** If the 10 hours are not furnished and billed in the first 12 consecutive months they are lost.

** Initial DSMT is a once-in-a-lifetime benefit.

• Follow-up DSMT in subsequent years:

** Does not exceed a total of 2 hours of individual or group DSMT each year:

** The 2 hours are furnished any time in a calendar year following the year in which the beneficiary completes the initial DSMT.

** The 2 hours can be furnished in increments of no less than 0.5 hour.

• The provider may order MNT for a more in-depth and/or individualized nutrition therapy (and related diabetes self-care activities) in the same year. (MNT max in one year is 3 hours, billed in 15 min increments.)

• DSMT and MNT cannot be billed on same day for the same beneficiary. Per Medicare’s “Medical Unlikely Edits” (new as of 2015), providers cannot bill over the maximum number of units per patient per day of the codes G0108 and G0109

Reasons for Claim Denial

The following are examples of situations where Medicare may deny coverage of DSMT services:

The beneficiary has exceeded the 10-hour limit of training,
The physician or qualified non-physician practitioner did not order the training, or
The individual furnishing the DSMT is not accredited by Medicare.

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