The Journal for Nurse Practitioners
Volume 4, Issue 9 , Pages 657-658, October 2008

Ordering Diabetes Self-Management Training

  • Carolyn Buppert

      Affiliations

    • Carolyn Buppert, CRNP, JD, practices law in Bethesda, Maryland.

Article Outline

 

Diabetes self-management training (DSMT) includes instruction in self-monitoring of blood glucose, education about diet and exercise, an insulin treatment plan developed for insulin-dependent patients, and motivation for patients to use the skills for self-management. In the Balanced Budget Act of 1997, Congress permitted Medicare to pay for DSMT if the treating physician or treating qualified non-physician practitioner (NPP) who is managing the patient's diabetic condition certifies that such services are needed. Medicare pays for DSMT when furnished by a certified provider who meets certain quality standards.

The referring physician or NPP “must maintain the plan of care in the beneficiary's medical record and documentation substantiating the need for training on an individual basis when group training is typically covered, if so ordered.” The order must include a statement signed by the physician (or NPP) that the service is needed as well as:

•The number of initial or follow-up hours ordered (the provider can order less than 10 hours of training)

•The topics to be covered in training (initial training hours can be used for the full initial training program or specific areas such as nutrition or insulin training)

•A determination that the beneficiary should receive individual or group training

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Who Needs DSMT? 

CMS says patients who meet the following criteria within the 12 months before the training begins would be eligible for DSMT:

•New-onset diabetes

•Change in treatment either from no diabetes medication to any diabetes medication or from oral diabetes medication to insulin

•At risk for complications based on inadequate glycemic control (ie, documented acute episodes of severe hypoglycemia or severe hyperglycemia requiring ER visits or hospitalization); diagnosis with eye disease related to diabetes; lack of feeling in feet; or foot problems such as ulcers, deformities, or amputation; or diagnosis with kidney disease-related to diabetes

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Who may provide DSMT? 

Physicians, nurse practitioners, dietitians, and certain other individuals may provide DSMT if they are certified as diabetes educators. For information on certification, visit www.ncbde.org.

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Who may bill for DSMT? 

Physicians or other providers or suppliers who bill Medicare for other individual services (such as hospital outpatient departments, renal dialysis facilities, or durable medical equipment suppliers) may bill for DSMT if the provider has an Education Recognition Program (ERP) certificate from the American Diabetes Association (ADA). Providers must furnish the Medicare carrier with the certificate before submitting claims.

As of January 1, 2002, registered dietitians have been eligible to bill on behalf of a DSMT program if they have a Medicare provider number. However, a dietitian may not be the sole provider of the DSMT service.

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Billing Rules 

The codes for DSMT are G0108 (Diabetes outpatient self-management training services, individual, per 30 minutes) and G0109 (Diabetes outpatient self-management training services, group session (2 or more) per 30 minutes. Medicare will pay only for those sessions actually attended by the patient and documented on attendance sheets.

If individual training has been provided and, subsequently, the carrier or intermediary determines that training should have been provided by a group, carriers and intermediaries down-code the reimbursement from individual to group level.

The provider of the DSMT service must keep the original order and any special conditions noted in a file. If the training under the order is changed, the physician or NPP must sign the order/referral changing the training.

The beneficiary is liable for services provided that are over the limited number of hours. Providers need to issue advance beneficiary notices if providing over the limited number of hours. If no valid advance beneficiary notice is provided to a beneficiary, the provider is liable for the charges for the extra hours.

Medicare covers individual training if:

•No group session is available within 2 months of the date the training is ordered

•The patient's physician or NPP documents in the patient's medical record that the patient has special needs resulting from conditions such as severe vision, hearing, or language limitations or other such special conditions as identified by the treating physician or NPP that will hinder effective participation in a group training session

•The physician orders additional insulin training

The need for individual training must be identified by the physician or NPP in the referral.

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Frequency of Training 

The initial year for DSMT is the 12-month period after the initial date. Medicare will cover initial training that meets the following conditions:

•Is furnished to a beneficiary who has not previously received initial or follow-up training under HCPCS codes G0108 or G0109

•Is furnished within a continuous 12-month period

•Does not exceed a total of 10 hours (the 10 hours of training can be done in any combination of half-hour increments)

•With the exception of 1 hour of individual training, training is usually furnished in a group setting, which can contain other patients besides Medicare beneficiaries

•One hour of individual training may be used for any part of the training, including insulin training

Medicare covers follow-up training under these conditions:

•No more than 2 hours individual or group training per beneficiary per year

•Group training that consists of 2 to 20 individuals who need not all be Medicare beneficiaries

•Follow-up training for subsequent years is based on a 12-month calendar after completion of the full 10 hours of training

•Follow-up training is furnished in increments of no less than one-half hour

•The physician or NPP treating the beneficiary must document in the medical record that the beneficiary is a diabetic.

PII: S1555-4155(08)00460-1

doi:10.1016/j.nurpra.2008.08.007

The Journal for Nurse Practitioners
Volume 4, Issue 9 , Pages 657-658, October 2008

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