Ask the Reimbursement Expert Q&A
This document provides a summary of DSME/T reimbursement-related questions that have been answered by the AADE Reimbursement Expert. We urge you to scan these topics to see if your question has already been answered. The information provided in this Q & A is intended as guidance only and is not intended as legal advice. Please contact each payer to determine the specific coverage and reimbursement practices and policies.
Positive Medicare Changes for DSMT in 2011
As a direct result of AADE's ongoing efforts with CMS, and with the assistance of AACE and JDRF, the Medicare payment for DSMT has significantly increased in 2011. Additionally, we were pleased that our request that DSMT be added to the list of approved telehealth services was accepted.
Reimbursement for telehealth
Effective January 2011, DSMT (G0108 and G0109) will be included in the list of reimbursable Medicare telehealth services. There are several requirements. Similar to reimbursement requirements for in-person education, the telehealth must be provided within a recognized program. CMS will also require that a minimum of 1 hour of in-person instruction is provided in the self-administration of injectable drugs to the individual during the year following the initial DSMT service. The injection training may be furnished through either individual or group DSMT services. By reporting the –GT or –GQ modifier with HCPCS code G0108 as a telehealth service, the distant site practitioner would certify that the beneficiary has received or will receive 1 hour of in-person DSMT services for purposes of injection training during the year following the initial DSMT service.
In addition to meeting the above DSMT specific criteria, Medicare requires that all the telehealth components as stated in the statute must be met in order for a provider to furnish telehealth services:
- Medicare telehealth services can only be furnished to an eligible telehealth beneficiary in an originating site. In general, originating sites must be located in a rural health professional shortage areas (HPSAs) or in a county outside of a metropolitan statistically area (MSA). The originating sites authorized by the statute are as follows: Offices of a physician or practitioner, Hospitals, CAHs, RHCs, FQHCs, Hospital-Based Or Critical Access Hospital-Based Renal Dialysis Centers, (including Satellites), SNFs and CMHCs.
- The following providers are approved by CMS to provider telehealth services (including DSMT telehealth services): Physician, Physician assistant (PA), Nurse practitioner (NP), Clinical nurse specialist (CNS), Nurse midwife, Clinical psychologist, Clinical social worker and Registered dietitian or nutrition professional.
Q: What is the average reimbursement for education?
A: The 2011 Medicare National Fee Schedule rates are: G0108 (per 30 minutes) $54.70 (increased from $23.45), G0109 (per 30 minutes/per patient) would pay $18.69 (increased from $12.99). Please note that these are the National Average rates. You can find state specific fee schedules at the CMS website at http://www.cms.gov/apps/physician-fee-schedule/overview.aspx. Enter the CPT code (s) and your state or locality, and the state specific Medicare fee should appear. Commercial plans may set their fees as a percentage of Medicare, i.e. 150%.
Q: Where can I find more information on DSMT reimbursement?
A: AADE has developed the following resources to address reimbursement
- For updated information about this rule, see the following transmittals:
- Follow-up training
- Guidelines for payment of DSMT (and a concise summary of the CMS DSMT rule)
Q: Where can a sample referral form for Diabetes Services, including DSMT be obtained?
A: Click here to find the DSMT/MNT referral form.
Q: Do private payers require ADA or AADE accreditation to bill DSME/T?
A: This will vary by payer, so you need to contact each individual plan to see if they require a DSMT program to be recognized by the AADE or ADA. Many private payers do not require AADE/ADA recognition in order to bill DSMT. Some payers may also require or suggest CPT codes 98960-98962.
Q: I am a CDE with a Medical provider number. Is it possible to bill DSMT services under my Medicare number?
A: RNs and CDEs are not recognized as Medicare providers, so they can't bill for services under their provider numbers. In order to bill Medicare for DSMT, you must have an accredited program through either the ADA or AADE. The billing for DSMT would then be done under the provider number that is the sponsor of the accredited program.
The practice of billing DSMT team members separately is addressed in the current Medicare policy. It states that "The program may also include a program coordinator, physician advisory, and other trainers. However, only one person or entity from the program bills Medicare for the whole program. The benefit provided by the program may not be subdivided for the purposes of billing Medicare." This Medicare Program Memorandum also addresses other issues that may be important to your practice. The AADE's online reimbursement modules also contain important information to your practice.
Q: Will Medicare allow payment for MNT and DSMT on the same day? Can physician services and MNT be billed on the same day?
A: MNT and DSMT can't be billed on the same day. The physician visit billed under an evaluation and management code (E/M) would need to meet medical necessity criteria and services provided must be above and beyond MNT. But if the MNT is billed under the RD's NPI and the E/M is billed under the physician's NPI, both should be allowed on the same day for the same patient.
Q: Who can bill CPT Code 95251 for interpretation of continuous glucose monitoring?
A: Only a MD or mid-level practitioner such as nurse practitioner, physician assistant or clinical nurse specialist can bill for interpretation of CGM and bill CPT code 95251.
Q: Can DSMT be rounded up? For example, if 48 minutes of DSMT are provided, can we round up and bill two 30-minute units?
A: There is no specific guidance by CMS on rounding up or down for the HCPCS DSMT codes. However, it is recommended that billing for DSMT under HCPCS codes G0108 and G0109 be based on actual face to face time and that providers do not round up.
Q: Can pharmacists bill Medicare for services provided by an accredited DSME/T program?
A: A pharmacist can be an instructor for an AADE accredited or ADA recognized DSMT program but they are not recognized as providers and therefore can't bill independently. The billing for DSMT would be done under the pharmacy's NPI number assigned to the DSMT program. Many pharmacies already bills services to Medicare either as a DME supplier or Part D provider, but the pharmacy must submit Form CMS-855B application to become a Part B provider. The pharmacy must also separately enroll with its Medicare Contractor, even if it has already completed a Form CMS-855S.
Q: Can Federally Qualified Health Clinics bill for DSMT and MNT services?
A: FQHCs with an accredited program can bill for DSMT or MNT services. However, only individual services qualify as a separate encounter. DSMT and MNT services may be provided in a group setting, but do not meet the criteria for a separate qualifying encounter, and therefore, cannot be billed as an encounter. Rather, the cost of group sessions is included in the calculation of the all-inclusive FQHC visit rate.
Q: Can Rural Health Clinics bill for DSMT and MNT services?
A: Separate payment to RHCs for these practitioners and services continues to be precluded. However, RHCs are permitted to become certified providers of DSMT services and report the cost of such services on their cost report for inclusion in the computation of their all-inclusive payment rates. Note that the provision of these services by registered dietitians or nutritional professionals might be considered incident to services in the RHC setting, provided all applicable conditions are met. However, they do not constitute an RHC visit, in and of themselves. All line items billed on TOB 71x with HCPCS code G0108 or G0109 will be denied.
Q: Which states have legislative mandates for diabetes care and supplies?
A: Click here to find that information. (Note: Employer self-funded plans (ERISA plans) are exempt from state mandates.)
Q: Is there a way to find out if a Medicare patient has previously received DSMT under Medicare? For example, if a patient has recently moved, how many hours of service in other states have they received?
A: Currently there is no central point to determine how many hours a patient has remaining for DSMT coverage. Medicare recommends you secure a signed ABN prior to the service being rendered if you think there is a likely hood that the service will be denied due to their limitation of covered hours. See our online reimbursement modules for detailed information on how covered hours are calculated and the proper use of an ABN.
Q: How many hours of DSMT does Medicare cover?
A: The number of hours of DSMT coverage depends on whether it is the initial year of DSMT coverage or follow-up training. Patients are eligible for 10 hours of DSMT during the initial year for DSMT which is the 12 month period following the initial date. If more than 10 hours of DSMT is provided in the initial year, the claim will be denied.
Follow-up training for subsequent years are based on a 12 month calendar year after the initial
Example #1 Beneficiary Exhausts 10 hours in the Initial Year (12 continuous months)
Patient receives first service: April 10, 2010
Patient completes initial 10 hours DSMT training: April, 2011
Patient is eligible for follow-up training: May 2011 (13th month begins the subsequent year)
Patient completes follow-up training: December, 2011
Patient is eligible for next year follow-up training: January, 2012
Example #2 Beneficiary Exhausts 10 hours Within the Initial Calendar Year
Patient receives first service: April 2010
Patient completes initial 10 hours of DSMT training, December 2010
Patient is eligible for follow-up training: January, 2011
Patient completes follow-up training: July 2011
Q: Does Medicare or private payers cover DSMT or MNT for pre-diabetes?
A: Currently, Medicare does not cover DSMT or MNT for pre-diabetes. However, Medicare is now covering some screening services for pre-diabetes. AADE continues legislative efforts to expand DMST for pre-diabetes. Some state Medicaid programs or commercial payers may cover a limited number of education hours for pre-diabetes.
Q: Can I expand my independent DSMT accredited programs to off-site locations such as a physician's office?
A: Yes, you can provide services in an off-site location, however you will need to notify the accrediting body such as ADA or AADE of the expansion of the off-site location. You will also need to inform the payers that you now provide services at a remote location. You should be aware of the Stark Law or other legal considerations such as inducements. Click here for additional details. You will also need to update your ADA recognition to include the remote site and have a signed lease agreement covering the time you use the physician's space. Click here for change in status form.
Q: Can DSMT be provided in the inpatient setting?
A: CMS will not reimburse DSMT services on a fee-for-service basis rendered to a beneficiary during an inpatient hospital stay. Most commercial payers follow CMS on this payment policy but verify directly with your commercial payers.
Q: Do diabetes educators in hospital-based outpatient DSME programs need to get individual National Provider Identification Numbers or can they use the hospital's NPI?
A: If you are an RD or an advanced practice RN (e.g. a Nurse Practitioner), you would need an NPI to claim DSMT services as an individual Medicare provider. If the DSMT program uses the hospital provider number (also an NPI number) to claim DSMT services, individual instructors would not need separate NPIs. If you are an RD and want to claim MNT services, you would need an NPI number.
Q: Does Medicare require a multi-disciplinary team in order to bill DSMT?
A: In March 2011, Medicare deleted the long-standing multi-disciplinary team requirement for reimbursement. CMS instructed its contractors to recognize that DSMT may be furnished by an individual RD, RN or pharmacist when those services are billed by, or on behalf of, the DSME/T entity accredited as meeting the National Standards for Diabetes Self-Management Education by the American Diabetes Association or the American Association of Diabetes Educators.
Q: We are currently initiating an insulin pump program at my facility. How do I bill for pump training?
A: Insulin pump training/education services may be part of DSMT and billed under HCPCS codes G0108 and G0109. These DSMT codes do require that your facility have an ADA or AADE recognized DSMT program. An NP or PA can also claim counseling services as a component of an evaluation & management services for a patient using the CPT codes 99212-99215. In addition, there are education codes such as 98960-98962. The following CPT codes are not paid by Medicare, but may be reimbursed by private payers for DSME/T or MNT. These codes do not require a DSME/T program to be recognized by either the ADA or the AADE.
|98960||Education and training for patient self-management by a qualified, non-physician health care professional using a standardized curriculum, face-to-face with patient (could include caregiver/family) each 30 minutes; individual patient.|
|98961||Education and training for patient self-management by a qualified, non-physician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; 2-4 patients.|
|98962||Education and training for patient self-management by a qualified, non-physician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; 5-8 patients.|
Q: I have always been under the impression that DME was always charged to Medicare Part B. However, I received some information (from a DME rep) that contradicted that info. The information was: if a patient goes to a pharmacy for their DME, it is quite possible that the pharmacy will charge their Part D and therefore, the patient could reach their donut-hole faster. The DME rep stated that in order for the pharmacy to charge the patient's Part B, they need some kind of software that is very costly and that's why it's easier for them to charge Part D. Is this true?
A: Medicare consider glucose meters and strips a Part B DME benefit. They would not be covered under Part D. Some commercial plans may cover meters/strips under pharmacy, but Medicare considers them DME. A pharmacy would need to be A DME provider in order to bill Medicare. A pharmacy would need different software/billing systems to bill DME than Part D. This would not impact a patient reaching their "donut hole" sooner because this would be a Medicare Part B benefit (not Part D). Remember that mail order glucose strips are included in the competitive bidding DME demonstration project.