Medicare Reimbursement Guidelines for DSMT

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The Centers for Medicare & Medicaid Services (CMS) provides reimbursement for Medicare beneficiaries for diabetes self-management training (DSMT), under certain conditions. Becoming familiar with the Medicare DSMT reimbursement guidelines can help increase a DSMES service’s financial sustainability. Reimbursement guidelines change often, so visit the Centers for Medicare & Medicaid Services resources listed below to ensure access to the most up to date information.

CMS Resources for DSMT

The following is a brief overview of the Medicare Part B DSMT benefit reimbursement rules, also known as the benefit’s coverage guidelines. The rules are very detailed and have been modified several times over the years; they may or may not change in the future.

DSMT providers must follow all CMS requirements to ensure legitimate payment and should always verify information before proceeding. In addition, the provider should verify that the patient has Medicare Part B insurance before furnishing the benefit and submitting a claim. Click here [ PDF – 259KB] for a link to a table that outlines the specific reimbursement rules. The table is provided courtesy of Mary Ann Hodorowicz Consulting, LLC.

Preliminary Steps for DSMT Providers to be Eligible for Reimbursement

DSMT services must have achieved accreditation from the Association of Diabetes Care & Education Specialists (ADCES) or recognition by the American Diabetes Association (ADA). However, accreditation/recognition alone is not the only eligibility requirement.

The DSMT provider must do the following:

The sponsoring organization or sponsoring individual must obtain a National Provider Identifier (NPI) number (Type I for an individual or Type II for an organization) AND be enrolled as a Medicare supplier for at least one service other than DSMT.
- If the sponsoring organization (e.g., clinic) is new to Medicare, a completed CMS Form 855B (business form) must be submitted to the regional Medicare Administrative Contractors (MAC) to enroll the organization in Medicare Part B.
  - Click here [PDF – 661 KB] to access CMS Form 855B.
  - Click here to learn more about MACs.
- If the sponsoring individual (e.g., registered dietitian) is new to Medicare, a completed CMS Form 855I must be submitted to enroll the individual as a Medicare Part B provider.
  - These forms can be downloaded from the regional MAC’s website or completed and submitted online, or click here [PDF – 522 KB] to access CMS Form 8551.
- Durable medical equipment (DME) and pharmacy providers must also enroll as Medicare Part B providers to bill for the DSMT benefit, even though they are enrolled as Medicare suppliers.
  - Submit a copy of the certificate of ADCES accreditation/ADA recognition along with a cover letter on your organization’s letterhead to the local MAC. Click here [PDF – 299 KB] to find MACs by state.
  - Confirm that the DSMT billing procedure codes (G0108 and G0109) have been entered into the billing system’s charge master.
  - Submit a copy of the certificate of accreditation/recognition to all contracted commercial payers and Medicaid and ensure DSMT billing procedure codes (G0108 and G0109) are included in the payer contracts.

What Medicare Covers in the DSMT Benefit

Medicare Part B (medical insurance for outpatient care, preventive services, ambulance services, and durable medical equipment) covers both initial and subsequent year (follow-up) outpatient diabetes self-management training (DSMT).

Initial DSMT

This is a “once-in-a-lifetime” Medicare benefit. A properly executed written or e-referral from the beneficiary’s treating diabetes provider (physician or qualified non-physician practitioner, such as a nurse practitioner, who is medically managing the beneficiary’s diabetes) is required.

Prior to the delivery of the initial DSMT, it is important to verify that the beneficiary has not received any initial DSMT in the past. This is because once the initial benefit is started, the 10 hours must be furnished within 12 consecutive months starting with the first date of service; after this time, any hours not furnished cannot be billed for Medicare payment.

If the beneficiary has received initial DSMT paid by another health insurance company, he/she is still eligible to receive the 10 hours of initial DSMT as a Medicare benefit.

One hour of individual DSMT is payable in the initial episode of care, but the remaining 9 hours must be furnished as group services unless one of three specific conditions are met, which allows all 10 hours to be furnished individually. These conditions are:

No DSMT group class is available for two months or longer from the date on the referral.
The referring provider indicates on the referral that the beneficiary has one or more barriers to group learning; examples are: reduced vision; reduced hearing; reduced cognition; language barrier; non-ambulatory.
The referring provider indicates on the referral that the beneficiary needs additional insulin training.

Important to note: If more than 10 hours of DSMT is billed in the first 12 consecutive months, the claim will be rejected by Medicare. If the beneficiary does not receive the entire 10 hours in the first 12 consecutive months, the balance of the 10 hours is forfeited.

DSMT Follow-Up

Two hours are allowed for DSMT follow-up in specific time frames following the initial intervention. For beneficiaries who start the initial DSMT in one year, and complete it in the following year, the follow-up may start in the month after the initial intervention is completed. The two hours of follow-up/year can then be furnished on a calendar year basis. For beneficiaries who start and complete the initial DSMT in one year, the follow-up may start in January of the following year. Any unused follow-up hours will be forfeited.

Important to note: A referral for follow-up DSMT is required. Meeting a specific condition for furnishing individual follow-up is not required.

Approved Places of Service

The following places of service are approved for in-person DSMT (not telehealth DSMT):

Hospital outpatient department
Critical access hospital
Private physician practice
Registered dietitian (RD) practice
Independent clinic (Freestanding FQHC and Independent Rural Health Clinic)
Federally qualified health center (FQHC)
Rural health clinic (RHC)
Home health agency
Skilled nursing facility (SNF)
Pharmacy
Durable medical equipment (DME) company

Important to note:

For hospitals: DSMT locations stemming from a hospital outpatient department must be hospital-owned provider-based clinics or physician groups. DSMT is not payable if furnished at alternate non-hospital, off-site locations.
For FQHCs: Only individual DSMT is payable by Medicare Part B.
- The FQHC may be able to include the cost of furnishing group DSMT on its annual cost report. It is best to first verify this with the regional MAC.
For RHCs: Only individual DSMT is payable by Medicare Part B.
- If there is a solo diabetes instructor, this person must be an RD and CDE.
- The RHC may be able to include the cost of furnishing group DSMT on its annual cost report. It is best to first verify this with the regional MAC.
For home health agencies: DSMT is only payable when furnished outside of the Medicare Part A home health benefit.
For SNFs: The SNF Part A benefit and the DSMT Part B benefit can be received by the beneficiary at the same time.

Excluded Places of Service:

Hospital inpatient
Nursing home
Renal dialysis facility

Procedure Codes

The 10 initial hours of DSMT and the 2 hours of follow-up DSMT are to be furnished in increments of no less than a 0.5-hour unit of time (30 minutes, face to face), as the procedure codes are 30-minute, time-based codes. Rounding of time furnished is not allowed for 30-minute time-based codes.

The procedure codes required by Medicare for the DSMT claim are:

G0108 – DSMT, individual, per 30 minutes
G0109 – DSMT, group (2 or more), per 30 minutes

Referral Documentation Requirements

Initial DSMT

Medical necessity for initial DSMT services must be established via a written or e-referral for DSMT by the treating provider. The treating provider (who must also be an active Medicare provider or in opt out status) is the physician or qualified non-physician practitioner (nurse practitioner, physician assistant, clinical nurse specialist) who is managing the beneficiary’s diabetes. The provider must maintain a plan of diabetes care in the beneficiary’s medical record, and submit a referral documenting:

That DSMT is needed.
If DSMT is to be group or individual.
If individual, one or more of the 3 conditions that warrant individual DSMT. A condition is not needed for FQHCs or RHCs, as only individual DSMT is payable.
The number of initial hours to be furnished (10 hours, or fewer than 10 hours).
The topics to be taught (i.e., all 10 topics or only specific topic(s), such as nutrition).
The diagnosis or valid, ICD-10 diagnosis code. (For type 1 and type 2 diabetes, a 5-character primary diagnosis code of diabetes is required.)
The signature of the referring provider. (A stamped signature is not allowed, but an e-signature in the EMR is allowed.)
The NPI number of the referring provider.
The beneficiary’s name.
The date.

Follow-up DSMT

The treating provider must maintain a plan of diabetes care in the beneficiary’s medical record and submit a referral documenting:

That follow-up DSMT is needed.
The diagnosis or valid, ICD-10 diagnosis code. (For type 1 and type 2 diabetes, a 5-character primary diagnosis code of diabetes is required.)
The signature of the referring provider. (A stamped signature is not allowed, but an e-signature in the EMR is allowed.)
The NPI number of the referring provider.
The beneficiary’s name.
The date.

Medicare Billing Provider Types and Related Information

Billing providers who are authorized by statute are:

Individual Medicare Part B providers (in active or official opt out status):
- Registered dietitians (RDs); qualified nutrition professionals (as specifically defined by Medicare); physicians (MDs and DOs); physician assistants; nurse practitioners; clinical nurse specialists; nurse midwives; clinical licensed social workers; and clinical psychologists.
Entity Medicare Part B providers authorized by statute:
- Hospitals; independent clinics; practices of physicians, RDs, qualified nutrition professionals, nurse practitioners, physician assistants and clinical nurse specialists; federally qualified health centers (FQHCs); rural health clinics; home health agencies, pharmacies, skilled nursing homes; durable medical equipment (DME) companies.
Only one individual or entity Medicare Part B provider can bill for all the hours of training in the initial and in the follow-up episodes of care; the benefit may not be subdivided among different providers for billing purposes.
DSMT service providers must be billing for at least one other Medicare service and receiving payment; providers cannot enroll in Medicare Part B just to bill for DSMT.

Resources

Medicare covers Diabetic Self-Management Training (DSMT) services furnished to beneficiaries with diabetes by certified providers. Visit the new DSMT Accreditation Program webpage for information on the certification process and accrediting organizations. Providers, patients, accrediting organizations, and stakeholders may contact the new helpdesk at DSMTAccreditations@cms.hhs.gov to submit questions or concerns about the program to CMS.

Click here to learn what Medicare reimbursement rates for DSMT are in your area.

Click here [PDF – 20 KB] to access the Clarification of National Standards Permitting Qualified RDs, RNs, or Pharmacists to Individually Furnish Diabetes Self-Management Training Services.

Click here [PDF – 584 KB] to access a table summarizing the current Medicare coverage guidelines for DSMT. The table is provided courtesy of Mary Ann Hodorowicz Consulting, LLC.