As part of the Medicare preventive service programs, three distinct services have been developed to assist providers and community wellness programs to provide care to diabetic patients.

Diabetes affects more than 25 percent of Americans aged 65 or older, and its prevalence is projected to increase approximately two-fold for all U.S. adults (ages 18-79) by 2050 if current trends continue. We estimate that Medicare spent $42 billion more in the single year of 2016 on beneficiaries with diabetes than it would have spent if those beneficiaries did not have diabetes; per-beneficiary, Medicare spent an estimated $1,500 more on Part D prescription drugs, $3,100 more for hospital and facility services, and $2,700 more in physician and other clinical services for those with diabetes than those without diabetes (estimates based on fee-for-service, non-dual eligible, over age 65 beneficiaries).

(https://innovation.cms.gov/initiatives/medicare-diabetes-prevention-program/)

Medicare has two approaches to diabetes prevention and control.  

Prevention:

Providers are encouraged to utilize services such as the Intensive Behavioral Therapy for Obesity to help patients manage their weight before obesity leads to diabetes in that patient.  Besides that, IBTO is the only approach service for diabetes prevention (CPT Code) available to providers without extra qualification, certification or license.

Starting in April 2018, Medicare has taken a radical and different approach to prevention by funding what is called the Medicare Diabetes Prevention Program or MDPP.  This service is not limited to licensed professionals such as physicians, NPs or PAs.

The following requirements must be met for payment of the Diabetes Prevention Program (MDPP.)

  • MDPP is prevention only and is not eligible for patients who have an existing diabetes diagnosis.
  • MDPP services can be provided for up to two years, consisting of one year of core and core maintenance sessions followed by up to one year of ongoing maintenance sessions, depending on eligibility, as described below.
    • CMS finalized a one-year limit on ongoing maintenance sessions (assuming attendance and weight loss performance goals are met)
  • MDPP beneficiaries must attend at least two out of three monthly ongoing maintenance sessions and maintain 5% weight loss at least once in the previous ongoing maintenance session interval to be eligible for additional intervals after the first.
  • CMS has assigned Healthcare Common Procedure Coding System (HCPCS) G-codes that MDPP suppliers will use to submit claims for payment when all the requirements for billing the codes have been met.

For more information about Medicare Diabetes Prevention Program please visit the Fact Sheet here.

Diabetes Management:

For patients beyond the Prevention stage, there are two services that Medicare has created for providers to manage existing diabetes.

  • Diabetes Self Management (DSMT)
  • Medical Nutrition Therapy (MNT)

These services have specific requirements which we will review below:

Diabetes Self Management (DSMT)

Medicare Part B (Medical Insurance) covers outpatient diabetes self-management training (DSMT) to teach patients to cope with and manage their diabetes. It includes tips for eating healthy, being active, monitoring blood sugar, taking drugs, and reducing risks. Medicare may cover up to 10 hours of initial DSMT. This training may include 1 hour of individual training and 9 hours of group training. Patients may also qualify for up to 2 hours of follow-up training each year if it takes place in a calendar year after the year you got your initial training. (https://www.medicare.gov/coverage/diabetes-self-mgmt-training.html)

For a better understanding of how to utilize Medicare’s Diabetes Self-Managment training program, please refer to the Step by Step Guide to Medicare’s Diabetes Self Management Training (DSMT) Reimbursement.

DSMT must be performed by an accredited diabetes service provider.  Providers and suppliers of DSMT services may submit requests for accreditation through the American Association of Diabetes Educators (AADE).

Medical Nutrition Therapy (MNT)

Medicare Part B (Medical Insurance) covers medical nutrition therapy (MNT) services and certain related services. A Registered Dietitian or nutrition professional who meets certain requirements can provide these services. MNT services may include:

(https://www.medicare.gov/coverage/nutrition-therapy-services.html)

Patients with Part B who meet at least one of the following conditions are eligible for MNT services:

  • Have diabetes
  • Have kidney disease
  • Have had a kidney transplant in the last 36 months

MNT services are different from normal billing procedures as the provider may not perform the service.  This service must be performed by a Registered Dietician or nutrition professional who has met certain requirements.

For more information on how to implement Medical Nutritional Services, we recommend visiting the Step-by-Step Guide to Medicare Medical Nutrition Therapy (MNT) Reimbursement

Federally Qualified Health Centers (FQHCs):

FQHCs bill based upon the new Prospective Payment System (PPS) which is a flat rate agreed upon by CMS.  A FQHC may not bill for services not listed within the PPS system.  Both MNT and DSMT codes are listed as services billable by FQHCs using the PPS rate.

CMS has interpreted the Social Security Act to state that a provider must see all patients who come to the FQHC for care before billing may occur.  The wellness team could play a significant part of the visit but it is important to note that CMS’s Regulations and Guidance paper states:

“When these services are provided by a clinical nurse specialist in the RHC/FQHC setting, they are considered “incident to” and do not constitute a billable visit.”

To avoid the “incident to” scenario, the FQHC must define clearly what the wellness staff will do during these services delineating the appropriate activities that can be done by auxiliary staff and then what elements of the visit must be done by the provider.  

Conclusion:

Diabetes is one of the main causes of preventable disease in this country.  Medicare estimates that in 2016 alone, more than $42 Billion was spent on Medicare recipients that wasn’t spent on their non diabetes counterparts.  Naturally, CMS has a vested interest in preventing or managing diabetes in all possible cases.

Diabetes services are a bit more complex than other preventive services offered by Medicare.  That being said, practices that offer these services can make huge inroads in preventing and/or treating diabetes for their patients.

The Medicare Annual Wellness Visit or Introduction to Medicare visit are both wonderful opportunities to identify and/or support a well-patient approach to patients with Diabetes.  Designing and implementing a comprehensive prevention program should definitely include a diabetes program.

CMS has made very distinct efforts to improve its diabetes support programs not only by the codes mentioned above but also through grant programs often implemented by Medicare Customer Services Providers known as their Quality Improvement Networks.  

We highly encourage primary care providers to integrate diabetes services into their wellness programs and don’t hesitate to reach out to programs like your local QIN to get the support needed to develop these services.

For more information about how Innovative Health Media can support your wellness program visit us on the web at www.MedicareAnnualWellnessVisit.com or contact us directly at (816) 866-5688.