medicare’s current diabetes self · required to submit claims to cms using standard claims forms...
TRANSCRIPT
Karen Ten Cate, MA, RD, CDE
Medicare’s Current Diabetes Self-Management Training
(DSMT) Coverage and Proposed Diabetes Prevention
Program (DPP) Rule
Friday, March 10, 2017
Diabetes Self-Management Training
(DSMT)
2
Medicare Part B beneficiaries with diabetes diagnosis using 1
of 3 labs.
Up to 10 hours of group training, with up to 1 hour of the 10
being individual.
• Have patients sign attendance roster at each session.
If special needs documented on referral, then all hours can be
individual
• Visual, hearing, language, cognitive impairment, mobility
limitations
Diabetes Self-Management Training
(DSMT) (cont.)
3
If additional insulin training ordered, can do all DSMT as
individual
If provider not offering a group in the next 2 months,
individual OK.
• Keep class schedule documented
The 10 hours must be used within 12 consecutive months of
beneficiary’s first session.
Must cover the content areas, as relevant to each patient, as
defined by the National Standards of DSME.
Who Can Bill for DSMT?
4
First, person or entity must already furnish and bill at least one
other Medicare service.
INDIVIDUALS - Can bill on behalf of all hours:
Physician
Physician Assistance (PA)
Registered Dietitian (RD)
Nurse Practitioner (NP)
Certified Nurse Specialist
Clinical Psychologist
Licensed Clinical Social Worker (LCSW)
The above clinicians may also teach, but at least one
instructor must also be an RD, RN or registered pharmacist.
Who Can Bill for DSMT? (cont.)
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ENTITIES
Durable Medical Equipment
A Pharmacy (not a pharmacist)
Hospital Outpatient Department
Clinic
Skilled Nursing Facility
MD/RD practice
Federally Qualified Health Center (patients must be seen
individually)
Home Health Agency - Part B bill allowable when separate
from Part A treatment plan.
Entities Not Able to Bill Separate
Part B claim for DSMT
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Hospital Inpatient
Hospice
Nursing Home
Rural Health Center (Part A)
End-Stage Renal Disease (ESRD) Facility
Must Be Accredited or Recognized
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American Association of Diabetes Educators (AADE)
Accreditation
America Diabetes Association (ADA) Recognized
Individual or Entity
Must Be Accredited or Recognized (cont.)
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Send copy of certificate to Medicare Administrative
Contractor, (MAC)
Both certifications require adherence to National Standards of
DSME/S.
Standard 5 requires an RD, RN or pharmacist to be one of the
instructors
Multi-disciplinary team recommended, but any of these three
could be a solo instructor.
• Remember a different clinician at that site might actually
bill, since RNs and pharmacists can not bill.
For Rural Health Clinics (who do not bill Part B anyway) if
the program has to have a solo instructor, it must be an RD.
Diagnostic Criteria for DSMT
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For Type 1 or 2, one of these must be documented:
Fasting Blood Glucose at or above 126 on 2 occasions, OR
Two-hour Oral Glucose Tolerance Test at or above 200mg/dL
on 2 occasions, OR
A Random Blood Glucose at or above 200, one overt symptom
• Overt symptom could be excess thirst, hunger, urination,
fatigue, blurry vision, unintended weight loss,
tingling/numbness in extremities, non-healing wounds
Gestational Diabetes
Provider to document ICD-10 code for Gestational Diabetes
Referral Requirement
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Patient’s name
Provider taking care of the patient’s diabetes, name and
signature
ICD-10 code indicating some kind of diabetes, E10-E11 range
If on insulin also add code Z79.4
Referral Requirement (cont.)
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One of the following:
• Fasting x 2,
• Two-hour GTT x2, or
• 1 Random BG in diagnostic range
Service to be provided:
• Initial DSMT (10 content areas) or Follow-up DSMT (after
initial 12 mo.)
• Needs individual DSMT due to special needs
Follow-Up
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Follow-up can start after initial DSMT (after first 12
consecutive months).
Two hours of follow-up can be billed in that 2nd year.
Two hours of follow-up DSMT is allowable in each calendar
year thereafter.
May be individual, group, or a combination. (No special needs
required.)
Follow-Up (cont.)
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New referral is required for follow-up.
Follow-up furnished and billed even if the patient did not
receive any initial DSMT under Medicare, or did not complete
the initial 10 hours.
Medicare Codes and Payment Amounts
14
G0108 = DSMT Individual
G0109 = DSMT Group
Payment amounts you see next are listed for each 30-minute
unit billed
CMS Physician Fee Schedule Search,
2017 Payment Amounts for Kentucky
Medicare Codes and Payment Amounts
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HCPCS Code Non-Facility Facility Non-Facility
Limiting
Charge
G0108 $51.35 $51.35 $56.10
G0109 $13.98 $13.98 $15.27
G0108, limit
billed to
patient/visit
6 units= 3 hrs 8 units= 4 hrs
G0109, limit
billed to
patient/visit
12 units= 6 hrs 12 units= 6 hrs
CMS Physician Fee Schedule Search,
2017 Payment Amounts for Kentucky
Diabetes Prevention Program (DPP)
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DPP Ruling for Medicare
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The 90-page Final Rule, CMS-1654-F, can be accessed at
https://www.diabeteseducator.org/docs/default-
source/practice/dpp/2017_pfs_dpp.pdf
The proposal, previously published July 15, 2016 is at
https://www.federalregister.gov/documents/2016/07/15/2016-
16097/medicare-program-revisions-to-payment-policies-under-
the-physician-fee-schedule-and-other-revisions
All information has been finalized, unless noted.
Description of the DPP Benefit
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The Medicare DPP (MDPP) core benefit is a 12-month
intervention that consists of at least 16 weekly core hour-long
sessions, over months 1-6, and at least 6 monthly core
maintenance sessions over months 6-12, furnished regardless
of weight loss.
Beneficiaries have access to three month intervals of ongoing
maintenance sessions after the core 12-month intervention if
they achieve and maintain the required minimum weight loss of
5 percent in the preceding three months.
MDPP was finalized as an additional preventive service,
Medicare cost-sharing will not apply to MDPP services.
ICD-10 Codes for Prediabetes
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R73.0 Abnormal glucose
Excludes:
• abnormal glucose in pregnancy (O99.81-)
• diabetes mellitus (E08-E13)
• dysmetabolic syndrome X (E88.81)
• gestational diabetes (O24.4-)
• glycosuria (R81)
• hypoglycemia (E16.2)
ICD-10 Codes for Prediabetes (cont.)
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R73.01 Impaired fasting glucose Elevated fasting glucose
R73.02 Impaired glucose tolerance (oral) Elevated glucose
tolerance
R73.09 Other abnormal glucose, Abnormal glucose NOS,
Abnormal non-fasting glucose tolerance, Latent diabetes,
Prediabetes
R73.9 Hyperglycemia, unspecified
Effective Oct 1, 2015
Proposed Reimbursement Parameters
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Payment would be tied to:
• Number of core sessions attended
• Weight loss of 5 percent or 9 percent of baseline weight
• Maintenance sessions if 5 percent or greater weight loss is
maintained
MDPP suppliers requirements:
• Attest to attendance/weight loss on claims
• Maintain records of attendance/weight loss for auditing
purposes
Proposed Payment Over the 16-Week
Program
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Core Sessions Payment per
Beneficiary
1 $25
4 $50
9 $100
5 percent weight loss achieved,
from baseline weight.
$160
9 percent weight loss achieved,
from baseline.
$25 (in addition to $160
above)
Max total for Core sessions $360https://innovation.cms.gov/Files/slides/mdpp-overview-slides.pdf
Proposed Payment for Maintenance
Sessions
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Maximum of 6 monthly sessions, over 6
months, during Year 1
Payment
3 Maintenance sessions attended (while
maintaining at least 5% loss from baseline)
$45
6 Maintenance sessions attended (while
maintaining at least 5% loss from baseline)
$45
Maximum Total for Maintenance Sessions $90
Maximum Total for First Year $450
Proposed Payment After Year 1
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Patient can attend more than 3 sessions per quarter, but the
reimbursement maxes out at 3 sessions per quarter, 12 sessions
per year.
Minimum 3 session attended per quarter. Payment
3 $45
6 $45
9 $45
12 $45
Maximum Total After First Year $180
Beneficiary Eligibility
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Enrolled in Medicare Part B
Have, as of the date of attendance at the first core session, a
body mass index (BMI) of at least 25 if not self-identified as
Asian or a BMI of at least 23 if self-identified as Asian
Have, within the 12 months prior to attending the first core
session, a hemoglobin A1c test with a value between 5.7 and
6.4 percent, a fasting plasma glucose of 110-125 mg/dL, or a 2-
hour plasma glucose of 140-199 mg/dL (oral glucose tolerance
test)
Beneficiary Eligibility (cont.)
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Have no previous diagnosis of type 1 or type 2 diabetes with
the exception of gestational diabetes
Do not have end-stage renal disease (ESRD)
Beneficiary Eligibility (Coverage Limits)
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MDPP benefit is once per lifetime per MDPP eligible
beneficiary
Ongoing maintenance sessions are available only if the MDPP
eligible beneficiary has achieved maintenance of weight loss
• A limit will be proposed in future rulemaking
Beneficiary Eligibility (Referral)
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Community
Self
Physician or other health care practitioner
MDPP Suppliers
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Proposed that DPP organizations have either preliminary or full
CDC DPRP in order to be eligible to enroll in Medicare as
MDPP supplier
• Proposal that entity has full CDC DPRP has been finalized
• Preliminary CDC DPRP status will be addressed in next
round of rulemaking
MDPP Suppliers
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Finalized - Entities with CDC CPRP recognition would be
eligible for enrollment in Medicare as MDPP supplier
Finalized – Existing Medicare providers need to enroll
separately as a MDPP supplier
MDPP Suppliers
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Enrolled CDC DPRPs will be subject to enrollment regulations
set forth in 42 CFR part 424, subpart P.
• Time limits for filing claims
• Requirements to report and return overpayments
• Procedures for suspending, offsetting, or recouping Medicare
payments in certain situations.
Coach Requirements
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Coaches must obtain NPIs
Coaches will not enroll in Medicare to furnish MDPP
MDPP supplier must keep an updated roster of all affiliated
coaches with:
• First and last name
• SSN
• NPI
Revocation
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MDPP supplier enrollment will be revoked if supplier criteria
no longer met.
• If program loses its CDC recognition status
• If not compliant with Medicare requirements
MDPP supplier may appeal revocation.
Can Virtual DPP Programs Enroll?
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No, as of now.
Proposed: Allow MDPP suppliers to furnish MDPP through
remote technologies.
• Not enough info to finalize
• CMS intends to address in future rulemaking
MDPP Supplier Information Technology
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Required to submit claims to CMS using standard claims forms
and procedures.
Maintain a crosswalk between beneficiary identifiers they
submit to CMS for billing and the participant identifiers they
provide CDC through session-level performance data.
Provide this crosswalk to CMS evaluator regularly.
MDPP Supplier (cont.)
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Maintain detailed documentation
Maintain PII and PHI in compliance with HIPPA (1996),
privacy laws, and CMS standards
Details must include:
• Test results
• Sessions attended
• The coach providing sessions
• Date and location of service
• Weight
• Further details to come.
Resources
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CDC’s National DPP website, how to apply for recognition
https://www.cdc.gov/diabetes/prevention/lifestyle-program/apply_recognition.html
Applying for an NPI https://www.cms.gov/Regulations-and-
Guidance/Administrative-Simplification/NationalProvIdentStand/apply.html
Provider Enrollment, Chain and Ownership System (PECOS) –can be used instead
of paper form CMS-855 https://www.cms.gov/medicare/provider-enrollment-and-
certification/medicareprovidersupenroll/internetbasedpecos.html
Free CMS claims submission software (available from your
MAC)https://www.cms.gov/Outreach-and-
Education/Outreach/FFSProvPartProg/Downloads/121211_standalone_message-.pdf
AADE Diabetes Prevention Program and assistance
https://www.diabeteseducator.org/practice/diabetes-prevention-program
Next Steps in DPP Coverage Process:
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Read and comment on the next rule
Continue to look for guidance from CMS
Visit CMS website to sign up for updates
https://innovation.cms.gov/initiatives/medicare-diabetes-
prevention-program/
Plan to begin enrollment in 2017 before benefit goes live 2018.
• Enrollment typically takes 45-60 days if all info is correct.
Connect with Us Reminders
39
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Thank You
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www.atomalliance.org
atom Alliance is a five-state initiative to ignite powerful and sustainable change in healthcare
quality. Formed as a partnership between three leading healthcare consultancies, atom Alliance is
working throughout Alabama, Indiana, Kentucky, Mississippi and Tennessee to improve quality
and achieve better outcomes in health and healthcare and at lower costs for the patients and
communities we serve.
Through atom Alliance, AQAF in Alabama, IQH in Mississippi and Qsource in Indiana, Kentucky
and Tennessee are carrying out an exciting strategic plan, with programs in place to convene,
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This material was prepared by the atom Alliance, the Quality Innovation Network-Quality
Improvement Organization (QIN-QIO), coordinated by Qsource for Tennessee, Kentucky, Indiana,
Mississippi and Alabama, under a contract with the Centers for Medicare & Medicaid Services
(CMS), an agency of the U.S. Department of Health and Human Services. Content presented does
not necessarily reflect CMS policy. 17.NCC.B2.02.001
Karen Ten Cate, MA, RD, CDE
Diabetes Education Specialist
Nancy Semrau, RN, BSBA, MHI
Quality Improvement Advisor
(502) 680-2391