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Diabetes Self-ManagementEducation/TrainingReimbursement GuideA resource to increase success in DSME/T billing and reimbursementThe following information can be used to aid in successfullyreceiving reimbursement for Diabetes Self-ManagementEducation/Training (DSME/T) services.

LOCATIONS AND PROVIDERSOnly specific healthcare disciplinesare authorized to be program instructorsfor DSME/T.ELIGIBLE HEALTH CARE ENTITIES(MEDICARE PART B PROVIDERS) Hospital outpatient departmentProgram instructors must include at leastone of the following disciplines: Durable medical equipment company Registered Dietitian Registered Dietitians in private practice Registered Nurse Independent clinic Registered Pharmacist State and public health clinic Note: Credential as a Certified DiabetesEducator (CDE) is not required, exceptif Registered Dietitian or nutritionprofessional is the sole instructor in theDSME/T program in a rural health clinic Home health agencyMEDICAREThe following Medicare Part B providerhealthcare entities and individualproviders of a certified DSME/T programcan render the benefit. Payment is madeunder Medicare’s modified physicianfee-for-service payment schedule.Note: The entities and individualsmust already be billing and receivingreimbursement from Medicare for at leastone other service. Physician, non-physician practitioner Pharmacy Skilled nursing home Federally Qualified Health Center(FQHC) Rural Health Clinic (RHC)Note: DSME/T is not covered whenfurnished in: a nursing home, hospice care,emergency department, or hospitalinpatient care.Telehealth DSME/T: For telehealthreimbursement, the billing provider mustadhere to Medicare’s separate telehealthcoverage guidelines. For the latestinformation on Medicare’s coverage oftelehealth, go to: rmation/Telehealth/index.htmlMEDICAIDWhen using Medicaid, the billing entity andrendering provider must be enrolled inMedicaid to be reimbursed.1

THE DSME/T BENEFITThe following health plans offer varyingdegrees of DSME/T reimbursement.MEDICARE*Initial: 10 hours (1 hour individual 9 hoursgroup) over continuous 12 months atdiagnosis or upon becoming a Medicarebeneficiary, if previously diagnosed.Individual: Can take the place of group ifthe patient has limitations such as a hearingor vision impairment, need for interpreter, orsome other limitation documented by theprescribing provider, or if there is no groupavailable within 2 months of the referral.Subsequent: 2 hours of group sessionsannually, if eligibleIncidental: The prescribing provider mayorder additional DSME/T for medicationchanges such as initiation of insulin.For more information view the MedicarePreventive Services Quick Reference Chart.MEDICAID*Initial: 10 hours (1 hour individual 9 hoursgroup) over continuous 12 months atdiagnosis or upon becoming a Medicaidbeneficiary, if previously diagnosed.Subsequent: 2 hours annually. Assessmentand provider referral are required.Incidental: The prescribing provider mayorder additional DSME/T for medicationchanges such as initiation of insulin.Note: It is recommended the patient orprovider confirm Medicaid Advantage planswill cover “incidental”.For more information go to the SouthDakota Medicaid Recipient Handbook.*To ensure reimbursement from Medicare or Medicaid, allcertified programs must submit a copy of their recognition/accreditation certificate to their Medicare AdministrativeContractor (MAC). See “billing” section for more information.PRIVATE INSURERSMost private insurers follow Medicarerequirements, but there may be somedifferences. Therefore, it is recommendedthe patient check with their specific plan.Note: For Federally Qualified HealthCenters (FQHC) and Rural Health Clinics(RHC) only individual (not group) DSME/T(G0108) is payable.2

DIAGNOSIS AND ELIGIBILITYIt is the responsibility of the prescribingprovider to conduct qualifying diagnostictests for diabetes diagnosis, maintaindocumentation of the referral (includingdiagnosis), and assign the diagnostic codewhich must be included on the referral.ICD-10 diagnosis code: Type 1 or Type 2diabetes must be defined in the documentationas a condition of abnormal glucose metabolismdiagnosed using one of the following criteria(excludes gestational diabetes mellitus, whichhas different criteria):When there is an identified need and areferral from a qualifying provider such as aphysician, Nurse Practitioner, or PhysicianAssistant, who is treating the beneficiary,the referral must include the InternationalClassification of Disease (ICD) code. Fasting Plasma Glucose 126 mg/dL,on two different occasions Oral Glucose Tolerance Test 200 mg/dL,on two different occasions Random Plasma Glucose glucose test 200 mg/d with symptom(s) of uncontrolleddiabetesNote: HbA1C is not accepted by Medicare as adiagnostic lab for Type 1 or Type 2 diabetes.See the CMS ICD-10 webpage for individualcoding rules and coding translations for ICD-10.For additional guidance, contact Noridian,South Dakota’s Medicare AdministrativeContractor (MAC).3

BILLINGThe following billing codes are usedfor DSME/T reimbursement. Additionalguidance specific to Federally QualifiedHealth Centers and Rural Health Clinicsis at the end of this section.Procedure codes for DSME/T G0108: individual outpatient DSME/Tper 30 minutes G0109: Group outpatient DSME/Tper 30 minutesNote: G-0108 and G-0109 for DSME/Tare not “incident to” codesIn order to bill for DSME/T, programs need tohave the following elements in place and/ortake the following actions.MEDICARETo bill Medicare, the DSME/T program must:Have recognition/accreditation fromeither American Association of DiabetesEducators (AADE) or the American DiabetesAssociation (ADA). DSME/T recognition through the SouthDakota Department of Health’s DiabetesEducation Recognition Program does notqualify for Medicare reimbursement The recognition/accreditation processthrough AADE or ADA is a separateprocess and does not guaranteeMedicare paymentBe part of an entity that is a Medicare provider. If new to Medicare, the sponsoringorganization will need to submit Form 855Ito enroll as a Medicare provider (obtainforms through Noridian Healthcare Solutions,LLC, —South Dakota’s local MedicareAdministrative Contractor (MAC)Obtain a NPI number specific to DSME/T Obtain NPI number only after receivingrecognition as a DSME/T provider andbecoming a Medicare provider To obtain an NPI number go to:https://nppes.cms.hhs.gov or for paperapplication, call 800-465-3203Submit notice of recognition/accreditationto Noridian Healthcare Solutions, LLC, SouthDakota’s local Medicare AdministrativeContractor (MAC) Do this after the Medicare billing statusand NPI number have been received AADE or ADA will provide the recognized/accredited program with a number andcertificate which must be included in thenotice to the local MACConfirm billing Confirm that the HCPCS (G0108 and G0109)codes for billing DSME/T are loaded in thebilling system4

BILLING CONT.Ensure the following documentation ispresent in the beneficiary’s medical record Referral by a qualifying medicalprovider (physician, Nurse Practitioner,Physician Assistant) Diagnosis of diabetes Appropriate procedure codes(G0108-individual, G0109-group)Note: If off-site locations are added to theDSME/T program, follow the process outlinedby the program’s recognizing/accreditingbody and notify the MAC.FEE SCHEDULESAccess the Physician Fee Schedule look-upto identify the state-specific Medicare fee perHCPCS code. (Co-payment, co-insurance,and deductibles apply).MEDICAIDTo bill Medicaid, the DSME/T Program must:Have recognition/accreditation fromeither the American Diabetes Association(ADA) or the South Dakota Departmentof Health (SD DOH).Be enrolled as a Medicaid provider—who is able to bill Medicaid (althoughsupporting members of the medical teamcan provide DSME/T services under therendering provider)Log into the SD MEDX portal—and do thefollowing, once recognized/accredited: Add the taxonomy code of 261QM2500Xto Step 3 “Specializations” Add the ADA or SD DOH certification toStep 5 “License/Certifications” Submit changes in steps 17-18 “SubmitProvider Modification” Fax a copy of the certification/accreditation (ADA or SD DOH)to 605-773-85205 Confirm that the Healthcare CommonProcedure Coding System (HCPCS) codefor billing individual DSME/T is loaded intothe billing systemEnsure the following documentation ispresent in the beneficiary’s medical record: Written referral from a qualifying providersuch as a physician, Nurse Practitioner, orPhysician Assistant Diagnosis of diabetes Any instructions by the ordering provider Any changes to the original planthat was signed by the provider ina separate referral Documentation of services renderedincluding:§ Content delivered§ Number of sessions/amount of time§ Appropriate procedure codes(G0108-individual, G0109-group)For more information on Mediciadreimbursement, see the South DakotaMedicaid Recipient Handbook.PRIVATE INSURERSReimbursement may vary by health plan.Programs are recommended to: Submit accreditation notice to contractedcommercial payers Verify that DSME/T codes G0108 andG0109 are included in the contract Contact them directly regardinga specific plan and client Note: Commercial plans may set their feesas a percentage of Medicare, i.e. 150%.

BILLING CONT.ABN REMINDERBeneficiaries should be asked to signan ABN if there is any question aboutcoverage. The Advanced Beneficiary Noticeholds the beneficiary liable for denials ofpayment from their health plan.The provider is liable if the ABN isnot valid or has not been signed.FEDERALLY QUALIFIEDHEALTH CENTERS (FQHCS)As of Jan 1, 2016 FQHCs are paid under theProspective Payment System (PPS).FQHCs with an accredited program, can billfor DSME/T services if: It is provided by a certified DSME/Tprovider as part of a recognized/accredited program (AADE or ADA forMedicare, ADA or SD DOH for Medicaidas described above) It is delivered in a 1:1 face-to-faceencounter, and billed using theappropriate Healthcare CommonProcedure Coding System (HCPCS) andsite of service revenue codesAdditional Considerations DSME/T is considered a medical visitand will not be reimbursed on the sameday any other medical visit is also billed DSME/T services provided in a groupsetting, do not qualify as a separatequalifying encounter. Rather, the costof group sessions is included in thecalculation of the all-inclusive FQHCvisit rate The beneficiary co-insurance isapplicable for DSME/T Specific Payment Codes for the FederallyQualified Health Center ProspectivePayment System (FQHC PPS)RURAL HEALTH CENTERS (RHC)RHCs are not paid separately under theMedicare fee-for-service methodology underPart B for DSME/T claims.RHCs are reimbursed from Medicare byreporting DSME/T cost on the facility’s costreport and paid at Medicare’s currentencounter all-inclusive rate.RHCs are not paid separately for DSME/T andMNT services. All line items billed on TOB 71xwith Healthcare Common Procedure CodingSystem (HCPCS) codes for DSME/T and MNTservices will be denied.RHCs are permitted to become certifiedproviders of DSME/T services and report thecost of such services on their cost report-- forinclusion in the computation of their allinclusive payment rates. Note that provisionof these services by Registered Dietitians ornutritional professionals might be considered“incident to” services in the RHC setting,provided all applicable conditions are met.However, they do not constitute an RHC visit,in and of themselves. Only individual DSME/T (G0108) ispayable for FQHCs Other diabetes counseling servicesprovided by other personnel at theFQHC that are not certified DSME/Tproviders may be considered ‘incidentto’ an FQHC provider and theappropriate code must be used6