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Preventive Services Guide

Diabetes Self-Management Training

According to the Centers for Disease Control and Prevention, approximately 38.4 million Americans have diabetes and 27.2 million people aged 65 years or older (48.8%) have been diagnosed with prediabetes.

Table of Contents

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Coverage Criteria and Frequency Limits

  • Coverage of services only for beneficiaries diagnosed with diabetes mellitus:
    • Fasting blood sugar ≥ 126 mg/dL on two different occasions
    • Two-hour post-glucose challenge ≥ 200 mg/dL on two different occasions or
    • Random glucose test over 200 mg/dL for a person with symptoms of uncontrolled diabetes
  • Requirements for coverage
    • Ordered by treating physician or qualified NPP managing beneficiary’s diabetic condition
      • Order/referral must include:
        • statement signed by physician or qualified NPP that service needed,
        • number of initial or follow-up hours of training ordered,
        • can order less than ten hours but not exceed ten hours,
        • topics to be covered in training, and
        • individual or group training determination.
    • Plan of care required to be documented in patient’s medical record
      • Original order by treating physician/NPP
        • Including any special conditions noted by physician
      • Must show services reasonable/medically necessary
    • When original order changed, order/referral must be:
      • signed by treating physician/NPP and
      • maintained in patient’s file in DSMT program records.
    • Must be provided by a designated certified provider within accredited DSMT program

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Initial DSMT Training

  • 12-month period following initial certification
    • Beneficiary has not previously received initial or follow-up training (G0108 or G0109)
    • Furnished within continuous 12-month period
    • Does not exceed total of ten hours
      • Any combination of 30-minute increments
    • Training usually furnished in group setting
      • Not all need to be Medicare beneficiaries
    • One hour of individual training may be used for any part, including insulin training

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Follow-Up DSMT Training

  • Based on 12-month calendar year after completion of full ten hours of initial training
  • No more than two hours of individual or group training per year
    • Furnished in increments of no less than 30 minutes
    • Group training consists of 2 to 20 individuals
      • Not all need to be Medicare beneficiaries
    • Documentation of diabetes diagnosis within patient’s medical record by treating physician or NPP
  • Follow-up training for subsequent years based on 12-month calendar year after completion of full ten hours of initial training
    • If beneficiary exhausts ten hours in initial year, eligible for follow-up training in next calendar year
    • If beneficiary does not exhaust ten hours in initial year, has 12 continuous months to exhaust initial training before two hours of follow-up training available

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Individual DSMT Training

  • Allowable when:
    • No group session available within two months of date training ordered
    • Patient has special needs resulting from conditions such as severe vision, hearing or language limitations, or other such special conditions that will hinder effective participation in group training session
    • Physician orders additional insulin training (can be provided via telehealth)
    • Need for individual training identified by physician or qualified NPP in referral

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HCPCS/CPT

  • G0108: Diabetes outpatient self-management training services, individual, per 30 minutes
    • bill one unit per each 30-minute increment
  • G0109: Diabetes outpatient self-management training services, group session (two or more), per 30 minutes
    • bill one unit per each 30-minute increment

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ICD-10 Coding

  • See the CMS ICD-10 web page for individual CRs and the specific ICD-10-CM codes Medicare covers for this service and contact your MAC for guidance.

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Who Can Perform?

  • Must be provided by a designated certified provider within accredited DSMT program
    • Certified provider is a physician or other individual or entity that:
      • provides outpatient self-management training services as well as other items and services for which payment may be made under the Medicare Program,
      • meets certain quality standards and
      • all providers/suppliers billing Medicare for other individual services considered certified.
  • Qualified DSMT programs include the following services:
    • Instruction in self-monitoring of blood glucose
    • Education about diet and exercise
    • Insulin treatment plan developed specifically for the patient
    • Motivation for beneficiaries to use self-management skills
  • The DSMT program must be accredited as meeting the quality standards by a CMS-approved national accreditation organization such as:
    • American Diabetes Association (ADA),

    • Association of Diabetes Care & Education Specialists (ADCES)

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Billing

  • All Medicare providers representing accredited DSMT program can bill and receive payment for entire DSMT program.
  • Enrolled registered dietitians and nutrition professionals may bill for, or on behalf of a DSMT entity as the DSMT certified provider regardless of which professional provided the actual education services.
    • Must have an order from a physician or qualified NPP who's treating the patient's diabetic condition
  • G0108 and G0109 may be rendered audio-only via telehealth

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Cost Sharing

  • Coinsurance applied
  • Deductible applied

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Reimbursement

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Nonparticipating Providers

  • Nonparticipating reduction applies
  • Limiting charge provision applies

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Billing Tips

  • DSMT benefit stand-alone billable service separate from IPPE
  • DSMT and MNT benefits allowed for same beneficiary in same year but not on same day
    • Requires separate referrals from physicians
  • If the DSMT program qualifies as a certified provider of DSMT services and is a distant site practitioner, the distant site’s physician or nonphysician practitioner may bill for DSMT services provided through telehealth and may do so on behalf of others who personally provide the services as part of the DSMT entity
  • An RD or nutrition professional must personally perform MNT services they bill for
  • Enrolled RDs and nutrition professionals may bill for, or on behalf of, a DSMT entity as the DSMT-certified provider regardless of which professional provided the actual education services.

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Common Claim Denials

  • Beneficiary exceeded ten hour training limit
  • Physician or qualified NPP did not order training
    • No proof of order in medical record
  • Individual furnishing DSMT is not accredited by Medicare

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Related Content

Revised 10/1/2024