Medicare s Current Diabetes Self-Management Training (DSMT) Coverage and Proposed Diabetes Prevention Program (DPP) Rule Karen Ten Cate, MA, RD, CDE Friday, March 10, 2017
Diabetes Self-Management Training (DSMT) Medicare Part B beneficiaries with diabetes diagnosis using 1 of 3 labs. Up to 10 hours of group training, with up to 1 hour of the 10 being individual. Have patients sign attendance roster at each session. If special needs documented on referral, then all hours can be individual Visual, hearing, language, cognitive impairment, mobility limitations 2
Diabetes Self-Management Training (DSMT) (cont.) If additional insulin training ordered, can do all DSMT as individual If provider not offering a group in the next 2 months, individual OK. Keep class schedule documented The 10 hours must be used within 12 consecutive months of beneficiary s first session. Must cover the content areas, as relevant to each patient, as defined by the National Standards of DSME. 3
Who Can Bill for DSMT? First, person or entity must already furnish and bill at least one other Medicare service. INDIVIDUALS - Can bill on behalf of all hours: Physician Physician Assistance (PA) Registered Dietitian (RD) Nurse Practitioner (NP) Certified Nurse Specialist Clinical Psychologist Licensed Clinical Social Worker (LCSW) The above clinicians may also teach, but at least one instructor must also be an RD, RN or registered pharmacist. 4
Who Can Bill for DSMT? (cont.) ENTITIES Durable Medical Equipment A Pharmacy (not a pharmacist) Hospital Outpatient Department Clinic Skilled Nursing Facility MD/RD practice Federally Qualified Health Center (patients must be seen individually) Home Health Agency - Part B bill allowable when separate from Part A treatment plan. 5
Entities Not Able to Bill Separate Part B claim for DSMT Hospital Inpatient Hospice Nursing Home Rural Health Center (Part A) End-Stage Renal Disease (ESRD) Facility 6
Must Be Accredited or Recognized American Association of Diabetes Educators (AADE) Accreditation America Diabetes Association (ADA) Recognized Individual or Entity 7
Must Be Accredited or Recognized (cont.) Send copy of certificate to Medicare Administrative Contractor, (MAC) Both certifications require adherence to National Standards of DSME/S. Standard 5 requires an RD, RN or pharmacist to be one of the instructors Multi-disciplinary team recommended, but any of these three could be a solo instructor. Remember a different clinician at that site might actually bill, since RNs and pharmacists can not bill. For Rural Health Clinics (who do not bill Part B anyway) if the program has to have a solo instructor, it must be an RD. 8
Diagnostic Criteria for DSMT For Type 1 or 2, one of these must be documented: Fasting Blood Glucose at or above 126 on 2 occasions, OR Two-hour Oral Glucose Tolerance Test at or above 200mg/dL on 2 occasions, OR A Random Blood Glucose at or above 200, one overt symptom Overt symptom could be excess thirst, hunger, urination, fatigue, blurry vision, unintended weight loss, tingling/numbness in extremities, non-healing wounds Gestational Diabetes Provider to document ICD-10 code for Gestational Diabetes 9
Referral Requirement Patient s name Provider taking care of the patient s diabetes, name and signature ICD-10 code indicating some kind of diabetes, E10-E11 range If on insulin also add code Z79.4 10
Referral Requirement (cont.) One of the following: Fasting x 2, Two-hour GTT x2, or 1 Random BG in diagnostic range Service to be provided: Initial DSMT (10 content areas) or Follow-up DSMT (after initial 12 mo.) Needs individual DSMT due to special needs 11
Follow-Up Follow-up can start after initial DSMT (after first 12 consecutive months). Two hours of follow-up can be billed in that 2 nd year. Two hours of follow-up DSMT is allowable in each calendar year thereafter. May be individual, group, or a combination. (No special needs required.) 12
Follow-Up (cont.) New referral is required for follow-up. Follow-up furnished and billed even if the patient did not receive any initial DSMT under Medicare, or did not complete the initial 10 hours. 13
Medicare Codes and Payment Amounts G0108 = DSMT Individual G0109 = DSMT Group Payment amounts you see next are listed for each 30-minute unit billed CMS Physician Fee Schedule Search, 2017 Payment Amounts for Kentucky 14
Medicare Codes and Payment Amounts HCPCS Code Non-Facility Facility Non-Facility Limiting Charge G0108 $51.35 $51.35 $56.10 G0109 $13.98 $13.98 $15.27 G0108, limit billed to patient/visit G0109, limit billed to patient/visit 6 units= 3 hrs 8 units= 4 hrs 12 units= 6 hrs 12 units= 6 hrs CMS Physician Fee Schedule Search, 2017 Payment Amounts for Kentucky 15
16 Diabetes Prevention Program (DPP)
DPP Ruling for Medicare The 90-page Final Rule, CMS-1654-F, can be accessed at https://www.diabeteseducator.org/docs/defaultsource/practice/dpp/2017_pfs_dpp.pdf The proposal, previously published July 15, 2016 is at https://www.federalregister.gov/documents/2016/07/15/2016-16097/medicare-program-revisions-to-payment-policies-underthe-physician-fee-schedule-and-other-revisions All information has been finalized, unless noted. 17
Description of the DPP Benefit The Medicare DPP (MDPP) core benefit is a 12-month intervention that consists of at least 16 weekly core hour-long sessions, over months 1-6, and at least 6 monthly core maintenance sessions over months 6-12, furnished regardless of weight loss. Beneficiaries have access to three month intervals of ongoing maintenance sessions after the core 12-month intervention if they achieve and maintain the required minimum weight loss of 5 percent in the preceding three months. MDPP was finalized as an additional preventive service, Medicare cost-sharing will not apply to MDPP services. 18
ICD-10 Codes for Prediabetes R73.0 Abnormal glucose Excludes: abnormal glucose in pregnancy (O99.81-) diabetes mellitus (E08-E13) dysmetabolic syndrome X (E88.81) gestational diabetes (O24.4-) glycosuria (R81) hypoglycemia (E16.2) 19
ICD-10 Codes for Prediabetes (cont.) R73.01 Impaired fasting glucose Elevated fasting glucose R73.02 Impaired glucose tolerance (oral) Elevated glucose tolerance R73.09 Other abnormal glucose, Abnormal glucose NOS, Abnormal non-fasting glucose tolerance, Latent diabetes, Prediabetes R73.9 Hyperglycemia, unspecified Effective Oct 1, 2015 20
Proposed Reimbursement Parameters Payment would be tied to: Number of core sessions attended Weight loss of 5 percent or 9 percent of baseline weight Maintenance sessions if 5 percent or greater weight loss is maintained MDPP suppliers requirements: Attest to attendance/weight loss on claims Maintain records of attendance/weight loss for auditing purposes 21
Proposed Payment Over the 16-Week Program Core Sessions 1 $25 4 $50 9 $100 5 percent weight loss achieved, from baseline weight. Payment per Beneficiary $160 9 percent weight loss achieved, from baseline. Max total for Core sessions $360 https://innovation.cms.gov/files/slides/mdpp-overview-slides.pdf $25 (in addition to $160 above) 22
Proposed Payment for Maintenance Sessions Maximum of 6 monthly sessions, over 6 months, during Year 1 3 Maintenance sessions attended (while maintaining at least 5% loss from baseline) 6 Maintenance sessions attended (while maintaining at least 5% loss from baseline) Payment $45 $45 Maximum Total for Maintenance Sessions $90 Maximum Total for First Year $450 23
Proposed Payment After Year 1 Minimum 3 session attended per quarter. 3 $45 6 $45 9 $45 12 $45 Payment Maximum Total After First Year $180 Patient can attend more than 3 sessions per quarter, but the reimbursement maxes out at 3 sessions per quarter, 12 sessions per year. 24
Beneficiary Eligibility Enrolled in Medicare Part B Have, as of the date of attendance at the first core session, a body mass index (BMI) of at least 25 if not self-identified as Asian or a BMI of at least 23 if self-identified as Asian Have, within the 12 months prior to attending the first core session, a hemoglobin A1c test with a value between 5.7 and 6.4 percent, a fasting plasma glucose of 110-125 mg/dl, or a 2- hour plasma glucose of 140-199 mg/dl (oral glucose tolerance test) 25
Beneficiary Eligibility (cont.) Have no previous diagnosis of type 1 or type 2 diabetes with the exception of gestational diabetes Do not have end-stage renal disease (ESRD) 26
Beneficiary Eligibility (Coverage Limits) MDPP benefit is once per lifetime per MDPP eligible beneficiary Ongoing maintenance sessions are available only if the MDPP eligible beneficiary has achieved maintenance of weight loss A limit will be proposed in future rulemaking 27
Beneficiary Eligibility (Referral) Community Self Physician or other health care practitioner 28
MDPP Suppliers Proposed that DPP organizations have either preliminary or full CDC DPRP in order to be eligible to enroll in Medicare as MDPP supplier Proposal that entity has full CDC DPRP has been finalized Preliminary CDC DPRP status will be addressed in next round of rulemaking 29
MDPP Suppliers Finalized - Entities with CDC CPRP recognition would be eligible for enrollment in Medicare as MDPP supplier Finalized Existing Medicare providers need to enroll separately as a MDPP supplier 30
MDPP Suppliers Enrolled CDC DPRPs will be subject to enrollment regulations set forth in 42 CFR part 424, subpart P. Time limits for filing claims Requirements to report and return overpayments Procedures for suspending, offsetting, or recouping Medicare payments in certain situations. 31
Coach Requirements Coaches must obtain NPIs Coaches will not enroll in Medicare to furnish MDPP MDPP supplier must keep an updated roster of all affiliated coaches with: First and last name SSN NPI 32
Revocation MDPP supplier enrollment will be revoked if supplier criteria no longer met. If program loses its CDC recognition status If not compliant with Medicare requirements MDPP supplier may appeal revocation. 33
Can Virtual DPP Programs Enroll? No, as of now. Proposed: Allow MDPP suppliers to furnish MDPP through remote technologies. Not enough info to finalize CMS intends to address in future rulemaking 34
MDPP Supplier Information Technology Required to submit claims to CMS using standard claims forms and procedures. Maintain a crosswalk between beneficiary identifiers they submit to CMS for billing and the participant identifiers they provide CDC through session-level performance data. Provide this crosswalk to CMS evaluator regularly. 35
MDPP Supplier (cont.) Maintain detailed documentation Maintain PII and PHI in compliance with HIPPA (1996), privacy laws, and CMS standards Details must include: Test results Sessions attended The coach providing sessions Date and location of service Weight Further details to come. 36
Resources CDC s National DPP website, how to apply for recognition https://www.cdc.gov/diabetes/prevention/lifestyle-program/apply_recognition.html Applying for an NPI https://www.cms.gov/regulations-and- Guidance/Administrative-Simplification/NationalProvIdentStand/apply.html Provider Enrollment, Chain and Ownership System (PECOS) can be used instead of paper form CMS-855 https://www.cms.gov/medicare/provider-enrollment-andcertification/medicareprovidersupenroll/internetbasedpecos.html Free CMS claims submission software (available from your MAC)https://www.cms.gov/Outreach-and- Education/Outreach/FFSProvPartProg/Downloads/121211_standalone_message-.pdf AADE Diabetes Prevention Program and assistance https://www.diabeteseducator.org/practice/diabetes-prevention-program 37
Next Steps in DPP Coverage Process: Read and comment on the next rule Continue to look for guidance from CMS Visit CMS website to sign up for updates https://innovation.cms.gov/initiatives/medicare-diabetesprevention-program/ Plan to begin enrollment in 2017 before benefit goes live 2018. Enrollment typically takes 45-60 days if all info is correct. 38
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Thank You Karen Ten Cate, MA, RD, CDE Diabetes Education Specialist Karen.TenCate@area-g.hcqis.org Nancy Semrau, RN, BSBA, MHI Quality Improvement Advisor Nancy.Semrau@area-G.hcqis.org (502) 680-2391 www.atomalliance.org atom Alliance is a five-state initiative to ignite powerful and sustainable change in healthcare quality. Formed as a partnership between three leading healthcare consultancies, atom Alliance is working throughout Alabama, Indiana, Kentucky, Mississippi and Tennessee to improve quality and achieve better outcomes in health and healthcare and at lower costs for the patients and communities we serve. Through atom Alliance, AQAF in Alabama, IQH in Mississippi and Qsource in Indiana, Kentucky and Tennessee are carrying out an exciting strategic plan, with programs in place to convene, teach and inform healthcare providers, engage and empower patients, and inspire, share knowledge and spread best practices with communities across the entire healthcare continuum. 40 This material was prepared by the atom Alliance, the Quality Innovation Network-Quality Improvement Organization (QIN-QIO), coordinated by Qsource for Tennessee, Kentucky, Indiana, Mississippi and Alabama, under a contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. Content presented does not necessarily reflect CMS policy. 17.NCC.B2.02.001