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Medicare Coverage for DSMT Benefit

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

Medicare Billing Provider Types

  • Individual Medicare Part B providers (inactive 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.

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.

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. 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 is 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 of the referral.
    • The referring provider indicates 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.

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

To increase the percentage of clean claims and reduce denials for DSMT, connecting with medical billing companies 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. To know more about our Diabetes billing and coding services you can contact us at 888-357-3226/ info@medicalbillersandcoders.com

Reference:

License for Use of Current Procedural Terminology, Fourth Edition (“CPT®”)

Medicare Reimbursement Guidelines for DSMT

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