Reimbursement Tips and Documentation Requirements for DSMT

1. Reimbursement Tips and Documentation Requirements for DSMT Medical Billers and Coders

2. 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, the Centers for Medicare & Medicaid Services resources listed below to ensure access to the most up to date information.

3. Reimbursement Tips • 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. • Approved Places of Service: • 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, and Durable medical equipment (DME) company. • Excluded Places of Service: • Hospital inpatient, Nursing home, and Renal dialysis facility

4. 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.

5. For SNFs: • The SNF Part A benefit and the DSMT Part B benefit can be received by the beneficiary at the same time. • 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.

6. The procedure codes required by Medicare for the DSMT claim are: G0108 – DSMT, individual, per 30 minutes; and G0109 – DSMT, group (2 or more), per 30 minutes Referral Documentation 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.

7. 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 a group or individual. • If an 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.

8. 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. • To increase the percentage of the clean claims and reduce denials for DSMT, connecting with medical billing company like Medical Billers and Coders (MBC) can be a great option. Our billers and coders have great experience in DSMT billing which reduces your billing worries and you to focus only on patient care.

9. Get in Touch Medical Billers and Coders Email : info@medicalbillersandcoders.com Toll Free no: 888-357-3226