Diabetes self-management education now covered under Medicaid

Friday, July 17, 2015 09:29 AM
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Services for accredited Diabetes Self-Management Education (DSME) to Medicaid members under certain conditions is a covered benefit beginning on July 1, 2015. Two new procedure codes are being added to the benefits of Colorado Medicaid, G0108 (individual classes) and G0109 (group classes). Facilities providing diabetes self-management education can bill using revenue code 0942 and identify the appropriate procedure codes on the claim. Individual providers that render diabetes self-management education can bill the procedure codes.

This benefit provides the following:

Up to 10 hours of diabetes-related training within a consecutive 12-month period following the submission of the first claim for the benefit which includes:

  • One hour for either a group or individual assessment;
  • Nine hours for group-only diabetes education;
  • Up to 2 hours of follow-up training each year after the initial 12-month period;
  • The training can be performed in any combination of 30 minute increments.

Client has a diagnosis of type 1, type 2, or gestational diabetes.

Diagnostic Criteria
According to national coding and diagnostic standards, diabetes is defined as a condition of abnormal blood glucose metabolism using the following diagnostic criteria:

  • A1C > 6.5% OR
  • Fasting glucose > 126 mg/dL on two or more occasions OR
  • Two-hour post glucose challenge > 200 mg/dL on two or more occasions OR
  • A random glucose test > 200 mg/dL for a person with symptoms of uncontrolled diabetes (16).

NOTE: DSME and Medical Nutrition Therapy (MNT) cannot be billed on the same day. DSME and MNT are complementary services and cannot be billed on the same service date.

A health care provider or entity interested in obtaining Medicaid reimbursement for DSME must become an accredited program provider. There are two accrediting organizations recognized by CMS: the American Diabetes Association’s Education Recognition Program (ERP) and the American Association of Diabetes Educators’ Diabetes Education Accreditation Program (DEAP). Colorado Medicaid follows the CMS policy of requiring accreditation from one of these programs.
For further information about each of these organizations, please contact AADE or ADA directly at:

American Association of Diabetes Educators (AADE)
(800) 338-3633

American Diabetes Association (ADA)

In Colorado, a number of programs are accredited and can be found at professional.diabetes.org/ERP_List.aspx  (accredited by the ADA) and at www.diabeteseducator.org/ProfessionalResources/accred/Programs.html#Colorado (accredited by AADE).

The recognized facilities or billing providers must be enrolled in Medicaid to be reimbursed. When DSME is provided in the ambulatory setting the rendering provider (or supervisor of the rendering provider) must also be enrolled in Medicaid.
Once a provider or entity achieves accreditation or recognition, Colorado Medicaid must be informed of the accreditation/recognition certificate from ADA or AADE for valid reimbursement. The accreditation/recognition certificate information must be submitted along with the Medicaid provider Identification and National Provider Identification Number (NPI) by completing the information at https://www.surveymonkey.com/s/DSMEinformation. Once this information is received, the provider or entity will be officially recognized by Medicaid to conduct a DSME program.

Medicaid Billing Detail
Initial education must be provided in a continuous 12-month period starting with the first date the DSME benefit is provided and is reflected on the claim. It is available to members who have not previously received any services billed under codes G0108 or G0109. In the initial year, the total number of hours billed cannot exceed 10 hours and must be delivered in no less than 30 minute increments. The member is eligible for one hour of individual training and nine hours in a group setting.
After the initial 12-month period, a maximum of 2 hours of follow-up education are available as either individual or group education.

To bill for DSME, a number of key elements must be in place. The beneficiary must have:

  • A diabetes diagnosis
  • A written referral for DSME, provided by a physician provider or qualified non-physician provider;

The DSME program must have:

  • Accreditation from either AADE or ADA;
  • A Medicaid provider who is able to bill;
  • A program for maintaining documentation of the beneficiary’s diabetes diagnosis in his or her medical record
  • FQHCs
    In order to be reimbursed for the diabetes self-management education services, the program at an FQHC must be recognized by the AADE or ADA. If the program at the FQHC is recognized, they can include the costs of diabetes self-management in the cost report and generate an encounter when there is a face to face visit with a listed provider (diabetes educators are not listed as eligible to generate an encounter). Even if the visit does not include a provider type that can generate an encounter the costs associated with a recognized DSME program can be included in the calculations that determine reimbursement amount.
    If the FHQC does not have a DSME program recognized by the AADE or ADA, the FQHC must refer the patient to a recognized DSME provider for reimbursed diabetes education.

    The procedure codes for this newly covered service are HCPCS G0108 (30 minute units, 2 units per day) for each individual counseling and G0109 (30 minute units, 2 units per day) for group counseling. Medicaid members are only allowed 20 combined units of DSME per year (up to two combined units of G0108 and up to 18 combined units of G0109). Fee schedule reimbursement for the procedure codes are:

    G0108 - $40.22
    G0109 - $11.04

    For More Information:
    If you need more information about accreditation, or have questions about setting up a DSME program, please contact either:

    AADE: DEAP@aadenet.org or call 1-800.338.3633
    ADA: ERP@diabetes.org or call 1-888-232-0822

    If you have general questions, please contact Christine Fallabel at The Colorado Department of Health Care Policy and Financing at Christine.Fallabel@state.co.us or call 303-866-5186 or Kelly McCracken at The Colorado Department of Public Health and Environment at Kelly.McCracken@state.co.us or call 303-692-2512.

    You may call Colorado Medicaid at 303-866-2993 for additional general inquiries, or for billing questions call 1-800-237-0757.

    Posted in: Colorado Medicine | Cover Story | LiveWire | Practice Management


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