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
G0108 and G0109
Medicare provides advantage of diabetes self-management training (DSMT) casework for beneficiaries who accept been afresh diagnosed with diabetes, bent to be at accident for complications from diabetes, or were ahead diagnosed with diabetes afore affair Medicare accommodation requirements and accept back become acceptable for advantage beneath the Medicare Program
A able DSMT affairs includes the afterward services:
Instructions in self-monitoring of blood glucose,
Education about diet and exercise,
An insulin analysis plan developed accurately for insulin abased patients, and
Motivation for patients to use the abilities for self-management.
DSMT casework are aimed against individuals with Medicare who accept afresh been impacted in any of the afterward situations by diabetes:
Problems authoritative claret sugar,
Beginning diabetes medication, or switching from articulate diabetes medication to insulin,
Diagnosed with eye ache accompanying to diabetes,
Lack of activity in anxiety or added bottom problems such as ulcers or deformities, or an amputation hasbeen performed,
Treated in an emergency allowance or accept backward brief in a hospital because of diabetes, or
Diagnosed with branch ache accompanying to diabetes.“
Coverage Information
Medicare provides advantage of DSMT casework alone if the alleviative physician or alleviative qualifiednon-physician practitioner managing the beneficiary’s diabetic action certifies that DSMT casework are needed. The apropos physician or able non-physician practitioner charge advance a plan of affliction in the beneficiary’s medical almanac and affidavit substantiating the charge for training on an alone base back accumulation training is about covered, if ordered. The adjustment charge additionally accommodate a account active by the physician or able non-physician practitioner that the account is bare as able-bodied as thefollowing information:
The cardinal of antecedent or after effect hours ordered
The capacity to be covered in training , and
A assurance if the almsman should accept alone or accumulation training.
