Referral Process

woman at doctor

To create a sustainable DSMES service, it is important to have a clear process for encouraging, receiving, and processing internal and external referrals. This multicomponent process includes managing relationships with external providers, determining participant eligibility for diabetes self-management training (DSMT)* coverage, knowing when referral is appropriate, completing documentation, and ensuring proper follow-up.

Referring and treating a person with diabetes requires a team-based approach. The most successful DSMES services are those that clearly define each team member’s roles and responsibilities. For example, one team member may be responsible for processing all incoming DSMES service referrals, while another is responsible for follow-up with the referring provider.

In addition, referring physicians and practices, diabetes educators, and DSMES service staff can use tracking systems and reminders to emphasize the importance of attendance and follow-up. It is also important for DSMES services and diabetes educators to identify and address other barriers to participation.

*Note: The Centers for Medicare & Medicaid Services (CMS) uses the term “training” (DSMT) instead of “education and support” (DSMES) when defining the reimbursable benefit (DSMT). This term relates specifically to Medicare billing.

Participant Eligibility

To qualify for DSMT coverage, a participant must have:

  • Documentation of a diagnosis of type 1, type 2, or gestational diabetes
    • Diagnosis can occur prior to Medicare Part B enrollment
  • Diagnosis must be made using the following criteria:14
    Participant Eligibility
    Fasting Blood Glucose ≥126 mg/dL on two separate occasions
    2-Hour Post-Glucose Challenge ≥200 mg/dL on two separate occasions
    Random Glucose Test >200 mg/dL with symptoms of uncontrolled diabetes
  • A written referral from the treating physician or qualified non-physician practitioner (such as a physician assistant (PA), nurse practitioner (NP), or advanced practice nurse (APN)15

Diabetes Education and Referral Algorithm

In 2015, the American Diabetes Association (ADA), Association of Diabetes Care & Education Specialists (ADCES), and the Academy of Nutrition and Dietetics issued a joint position statement on the importance of DSMES in type 2 diabetes.1 The position statement includes an evidence-based diabetes education algorithm that visually depicts when to refer people with type 2 diabetes to DSMES and defines four critical times for delivery of DSMES:

  1. At diagnosis
  2. During annual assessment
  3. When a person with diabetes has new complicating factors
  4. Upon transitions in care

Click here [PDF – 60 KB] for a full-page version of the Diabetes Self-Management Education and Support for Adults with Type 2 Diabetes: ALGORITHM ACTION STEPS.

The diabetes education algorithm serves several key purposes:

  • It provides key information on the self-management skills that are necessary at each of the four critical periods.
  • It offers health care systems, providers, and staff a guide for when and how to refer to DSMES and furnishes action steps for delivering diabetes education.
  • Educators can use the algorithm as a marketing tool when having conversations with providers.

For more information, see the Joint Statement from ADA, ADCES, and Academy of Nutrition and Dietetics. Click here for Figure 1, the algorithm of care, and here for Figure 2, for content at the four critical time points.

Referral Requirements and Documentation

DSMES services will be covered by Medicare if the treating physician or qualified practitioner documents the need for DSMES in the form of a referral or order. There are many documentation requirements for referrals, and based on place of service (e.g., federally qualified health center, rural health center, hospital, etc.), there may be extra and/or different documentation requirements. Please click here [PDF – 584 KB] for a detailed list of documentation requirements.

The referring provider must keep the care plan and supporting documentation in the participant’s medical record. In addition, the DSMES service must maintain the original referral and any other special conditions noted by the referring practitioner. If the referring practitioner makes changes to the order, the referring practitioner must sign it, and the DSMES service must keep the changes in the service files.

For more information on referral requirements and documentation, please visit the resources below:

Diabetes Services Order Form Backgrounder on DSMES and Medical Nutrition Therapy (MNT) Services [PDF – 512 KB]:
This document provides background on why referral forms look the way they do.

Centers for Medicare & Medicaid Services (CMS) [PDF – 107 KB]:
View the CMS website to search for the most recent referral requirements and instructions for DSMT referrals.

Sample referral forms:

Association of Diabetes Care & Education Specialists Sample Referral Form:
This example includes referral components plus information that may be helpful for treatment and education.

American Diabetes Association Sample Referral Form [PDF – 25 KB]:
This example includes referral components plus information that may be helpful for treatment and education.

American Diabetes Association Short Sample Referral Form [PDF – 68 KB]:
This is a brief document that includes referral components.