Medicare Reimbursement Guidelines

Preliminary steps for reimbursement

DSMT providers must follow all CMS requirements to ensure the quality of services for payment and should always verify information before proceeding. In addition, the provider should verify that the patient has Medicare Part B insurance before furnishing the benefit and submitting a claim.

DSMT services must have achieved accreditation from the Association of Diabetes Care & Education Specialists (ADCES) OR recognition by the American Diabetes Association (ADA).

In addition, the DSMT provider must do the following:

1. The sponsoring organization or sponsoring individual must obtain a National Provider Identifier (NPI) number (Type I for an individual or Type II for an organization) AND be enrolled as a Medicare supplier for at least one service other than DSMT.

• If the sponsoring organization (e.g., clinic) is new to Medicare, a completed CMS Form 855B (business form) must be submitted to the regional Medicare Administrative Contractors (MAC) to enroll the organization in Medicare Part B.
• CMS Form 855B
• Learn more about MACs.

2. If the sponsoring individual (e.g., registered dietitian) is new to Medicare, a completed CMS Form 855I must be submitted to enroll the individual as a Medicare Part B provider.

• These forms can be downloaded from the regional MAC's website or completed and submitted online (see CMS Form 8551).

3. Durable medical equipment and pharmacy providers must also enroll as Medicare Part B providers to bill for the DSMT benefit even though they are enrolled as Medicare suppliers.

• Submit a copy of the certificate of ADCES accreditation or ADA recognition along with a cover letter on your organization's letterhead to the local MAC. Find MACs by state.
• Confirm that the DSMT billing procedure codes (G0108 and G0109) have been entered into the billing system's charge master.
• Submit a copy of the certificate of accreditation or recognition to all contracted commercial payers and Medicare and ensure DSMT billing procedure codes are included in the payer contracts.

What Medicare covers

Medicare Part B covers both initial and follow-up DSMT:

Initial DSMT

This is a "once-in-a-lifetime" Medicare benefit. A properly executed written or e-referral from the beneficiary's treating diabetes provider (physician or qualified nonphysician practitioner, such as a nurse practitioner, who is medically managing the beneficiary's diabetes) is required.

Before the initial DSMT, verify that the beneficiary has not received any initial DSMT in the past. Once the initial benefit is started, the 10 hours must be furnished within 12 consecutive months, starting with the first date of service. After this time, any hours not furnished cannot be billed for Medicare payment.

If the beneficiary has received initial DSMT paid by another health insurance company, they are still eligible to receive the 10 hours of initial DSMT as a Medicare benefit.

One hour of individual DSMT is payable in the initial episode of care, but the remaining 9 hours must be furnished as group services unless one of three specific conditions is met, which allows all 10 hours to be furnished individually. These conditions are:

1. No DSMT group class is available for two months or longer from the date on the referral.
2. The referring provider indicates on the referral that the beneficiary has one or more barriers to group learning. Examples include reduced vision, reduced hearing, reduced cognition, language barrier, or non-ambulatory.
3. The referring provider indicates on the referral that the beneficiary needs additional insulin training.

Important note: If more than 10 hours of DSMT are billed in the first 12 consecutive months, the claim will be rejected by Medicare. If the beneficiary does not receive the entire 10 hours in the first 12 consecutive months, the balance of the 10 hours is forfeited.

Follow-up DSMT

Two hours are allowed for follow-up each year after the initial DSMT. For beneficiaries who start the initial DSMT in one year and complete it in the following year, the follow-up may start in the month after the initial DSMT is completed. The two hours of follow-up per year can then be furnished on a calendar year basis. For beneficiaries who start and complete the initial DSMT in one year, the follow-up may start as of January of the following year. Any unused follow-up hours will be forfeited.

Additional details

A referral for follow-up DSMT is required.

Approved places of service

The following places of service are approved for in-person DSMT (not telehealth DSMT):

• Hospital outpatient department.
• Critical access hospital.
• Private physician practice.
• Registered dietitian (RD) practice.
• Independent clinic (freestanding Federally Qualified Health Center [FQHC] or independent rural health clinic [RHC]).
• Home health agency.
• Skilled nursing facility (SNF).
• Pharmacy.
• Durable medical equipment company.

Excluded places of service

• Hospital inpatient facility.
• Nursing home.
• Kidney dialysis facility.

Important notes

For hospitals: DSMT locations in a hospital outpatient department must be hospital-owned provider-based clinics or physician groups. DSMT is not payable if furnished at alternate nonhospital, off-site locations.

For FQHCs: Only individual DSMT is payable by Medicare Part B. The FQHC may be able to include the cost of furnishing group DSMT on its annual cost report. It is best to first verify this with the regional MAC.

For RHCs: Only individual DSMT is payable by Medicare Part B. If there is a solo diabetes instructor, this person must be both a registered dietitian (RD) and a certified diabetes care and education specialist (CDCES). The RHC may be able to include the cost of furnishing group DSMT on its annual cost report. It is best to first verify this with the regional MAC.

For home health agencies: DSMT is only payable when furnished outside of the Medicare Part A home health benefit.

For SNFs: The SNF Part A benefit and the DSMT Part B benefit can be received by the beneficiary at the same time.

Procedure codes for DSMT claims

The 10 initial hours of DSMT and the 2 hours of follow-up DSMT are to be in increments of no less than 30 minutes, and face to face. Rounding of time is not allowed for 30-minute time-based codes.

The procedure codes required by Medicare for the DSMT claim are:

• G0108 – DSMT, individual, per 30 minutes.
• G0109 – DSMT, group (2 or more), per 30 minutes.

Referral documentation requirements

Initial DSMT

The treating provider must establish medical necessity for initial DSMT services via a written or e-referral. The treating provider (who must also be an active Medicare provider or in official opt-out status) is the physician or qualified nonphysician practitioner (nurse practitioner, physician assistant, clinical nurse specialist) who is managing the beneficiary’s diabetes. The provider must maintain a plan of diabetes care in the beneficiary’s medical record.

The DSMT referral should document:

• Need for DSMT.
• If DSMT is group or individual.
• If individual, one or more of the three conditions that warrant individual DSMT.
  • A condition is not needed for FQHCs or RHCs, as only individual DSMT is payable.
• Number of initial hours (10 or less).
• Topics that will be taught.
• Diagnosis or valid ICD-10 diagnosis code.
  • Types 1 and 2 diabetes require a 5-character primary diagnosis code.
• Beneficiary's name.

Follow-up DSMT

The treating provider must maintain a diabetes care plan in the beneficiary's medical record. The referral must also document the following:

• Need for follow-up DSMT.
• Diagnosis or valid ICD-10 diagnosis code.
  • Types 1 and 2 diabetes require a 5-character primary diagnosis code of diabetes.

Note

Initial and follow-up referrals should also include the date, the referring provider's signature and National Provider Identifier (NPI) number. Stamped signatures are not allowed, but e-signatures are allowed for electronic medical records (EMR).

Medicare billing provider types and related information

Individual Medicare Part B providers (in active or official opt-out status)

• Registered dietitians (RDs) and qualified nutrition professionals (defined by Medicare).
• Physicians and physician assistants.
• Nurse practitioners, clinical nurse specialists, and nurse midwives.
• Clinical licensed social workers and clinical psychologists.

Entity Medicare Part B providers authorized by statute

• Hospitals.
• Independent clinics.
• Medical practices belonging to
  • RDs and qualified nutrition professionals.
  • Physicians and physician assistants.
  • Nurse practitioners and clinical nurse specialists.
• FQHCs and RHCs.
• Home health agencies, pharmacies, and skilled nursing homes.
• Durable medical equipment companies.

Additional information

Only one Medicare Part B provider (individual or entity) can bill for all DSMT hours in the initial and follow-up periods. The benefit cannot be subdivided among different providers for billing purposes.

Providers cannot enroll in Medicare Part B just to bill for DSMT. They must be billing at least one other Medicare Part B service and receiving payment.

Resources

Visit the reimbursement resources page for documents and other resources.

For questions and concerns about the program, providers, patients, accrediting organizations, and stakeholders may contact the new CMS helpdesk: DSMTAccreditations@cms.hhs.gov