Medicare provides coverage of diabetes self-management training (DSMT) services for beneficiaries who have been recently diagnosed with diabetes, determined to be at risk for complications from diabetes, or were previously diagnosed with diabetes before meeting Medicare eligibility requirements and have since become eligible for coverage under the Medicare Program
A qualified DSMT program includes the following services:
* Instructions in self-monitoring of blood glucose,
* Education about diet and exercise,
* An insulin treatment plan developed specifically for insulin dependent patients, and
* Motivation for patients to use the skills for self-management.
DSMT services are aimed toward individuals with Medicare who have recently been impacted in any of the following situations by diabetes:
*Problems controlling blood sugar,
*Beginning diabetes medication, or switching from oral diabetes medication to insulin,
*Diagnosed with eye disease related to diabetes,
*Lack of feeling in feet or other foot problems such as ulcers or deformities, or an amputation hasbeen performed,
*Treated in an emergency room or have stayed overnight in a hospital because of diabetes, or
Diagnosed with kidney disease related to diabetes.``
Medicare provides coverage of DSMT services only if the treating physician or treating qualifiednon-physician practitioner managing the beneficiary’s diabetic condition certifies that DSMT services are needed. The referring physician or qualified non-physician practitioner must maintain a 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 ordered. The order must also include a statement signed by the physician or qualified non-physician practitioner that the service is needed as well as thefollowing information:
*The number of initial or follow-up hours ordered (the physician can order less than 10 hours, but cannot exceed 10 hours of training),
*The topics to be covered in training (initial training hours can be used to pay for the full initial *training program or specific areas, such as nutrition or insulin training), and
A determination if the beneficiary should receive individual or group training.
Procedure Codes and Descriptors
The following Healthcare Common Procedure Coding System (HCPCS) codes listed are used to report DSMT services
G0108 - Diabetes outpatient self-management training services, individual, per 30 minutes
G0109 - Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes
Note: For FQHCs, codes representing group sessions do not constitute a separate billable visit.
Reasons for Claim Denial
The following are examples of situations where Medicare may deny coverage of DSMT services:
The beneficiary has exceeded the 10-hour limit of training,
The physician or qualified non-physician practitioner did not order the training, or
The individual furnishing the DSMT is not accredited by Medicare.