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Diabetes Care Practice-Based Resources

Diabetes Self-Management Education Services

FAQ-Reimbursement Laws in TN

  1. Does the law require private insurance plans to cover DSME/T? 
    1. Yes
  2. What triggers coverage of DSME/T?
    1. Diabetes diagnosis 
    2. Change in health status
    3. Need for re-education
  3. Is there a coverage cap for DSME/T?
    1. No
  4. What type of cost-sharing does the law on DSME/T explicitly permit for private insurance?
    1. Co-Insurance
    2. Deductibles
  5. Does the law on DSME/T specify cost-sharing amounts?
    1. Yes, not greater than other amounts under the plan
  6. What type(s) of health care practitioners can order initial DSME/T?
    1. Physician
  7. What type of health care practitioners can deliver DSME/T?
    1. Any licensed health care practitioner
    2. Nurse Practitioner 
    3. Pharmacist
    4. Physician 
    5. Registered Dietitian
    6. Registered Nurse 
  8. What qualifications are required for DSME/T providers?
    1. Accreditation by national DSME/T certification body 
    2. Designation by Physician 
    3. Must have knowledge of diabetes or DSME/T
    4. State licensing or certification 
  9. What program features are required as a part of DSME/T?
    1. Nutritional component 
  10. In what settings may DSME/T be conducted?
    1. Home health settings
    2. Outpatient settings
  11. Does the law require the state Medicaid program to cover DSME/T?
    1. Yes
  12. What triggers Medicaid coverage of DSME/T?
    1. Diabetes diagnosis 
    2. Change in health status 
    3. Change in treatment
    4. Need for re-education 
  13. Is there a Medicaid coverage cap for DSME/T?
    1. No
  14. What type(s) of health care practitioners can order initial DSME/T covered by Medicaid?
    1. Physician 
  15. What type(s) of health care practitioners can deliver DSME/T covered by Medicaid?
    1. Any licensed health care practitioner 
    2. Nurse Practitioner
    3. Pharmacist
    4. Physician
    5. Registered Dietitian
    6. Registered Nurse
  16. What type of qualifications are required for DSME/T providers when DSME/T is covered by Medicaid?
    1. Accreditation by national DSME/T certification body 
    2. Designation by Physician 
    3. Must have knowledge of Diabetes or DSME/T
    4. State licensing or certification 
  17. What program features are required as a part of DSME/T covered by Medicaid?
    1. Nutritional component
  18. In what settings may Medicaid-covered DSME/T be conducted?
    1. Home health settings
    2. Outpatient settings

Statutory Authority for Diabetic Self-Management Training (DSMT) [Medicare]

Section 4105(a) of the Balanced Budget Act of 1997 (BBA) (pub. L. 105-33), enacted on August 5, 1997, provides for Medicare coverage for DSMT services provided by a “certified provider.” Section 4105 of the BBA amended section 1861 of the Social Security Act (The Act) by adding a new section (q)(q). 

Section 1861(qq) of the Social Security Act (the Act) provides CMS with the statutory authority to regulate Medicare outpatient coverage of DSMT services. 

The term “diabetes outpatient self-management training services” is defined at 1861(q)(q)(1) of the Act as “educational and training services furnished …to an individual with diabetes by a certified provider… in an outpatient setting by an individual or entity who meets the quality standards…, but only if the physician who is managing the individual’s diabetic condition certifies that such services are needed under a comprehensive plan of care related to the individual’s diabetic condition to ensure therapy compliance or to provide the individual with necessary skills and knowledge (including skills related to the self-administration of injectable drugs) to participate in the management of the individual’s condition. 

The term “certified provider” is defined at section 1861(q)(q)(2)(A) of the Act as “a physician, or other individual or entity designated by the Secretary, that, in addition to providing diabetes outpatient self-management training services, provides other items or services for which payment may be made under this title.”   

Section 1861(q)(q)(2) provides that the Secretary may recognize a physician, individual, or entity that is recognized by an organization as meeting standards for furnishing these services as a certified DSMT provider. This statute also provides that a physician or other individual or entity shall be deemed to have met such standards if they meet applicable standards originally established by the National Diabetes Advisory Board. 

Section 1861(q)(q)(2)(B) of the Act states that “a physician, or such other individual or entity, meets the quality standards… if the physician, or individual or entity, meets quality standards established by the Secretary, except that the physician or other individual or entity shall be deemed to have met such standards if the physician or other individual or entity meets applicable standards originally established by the National Diabetes Advisory Board and subsequently revised by organizations who participated in the establishment of standards by such Board, or is recognized by an organization that represents individuals (including individuals under this title) with diabetes as meeting standards for furnishing the services.” 

Additionally, section 4105(c)(1) of the BBA requires the Secretary to establish outcome measurements for purposes of evaluating the improvement of the health status of Medicare beneficiaries with diabetes. 

A final rule (65 FR 83130) was published in the Federal Register on December 29, 2000, which implemented the BBA provisions addressing the coverage, payment, quality standards, and accreditation requirements for DSMT. This final rule also implemented the DSMT regulations which are codified at Title 42 of the Code of Federal Regulation (CFR) sections 410.140 to 410.146. 

What Medicare Covers in the DSMT Benefit 

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

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 are 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 on the referral. 

The referring provider indicates on 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. 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. 

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

Approved Places of Service 

  • Pharmacy 

Billing & Coding:  

Procedure Codes 

The 10 initial hours of DSMT and the 2 hours of follow-up DSMT are to be furnished in increments of no less than a 0.5-hour unit of time (30 minutes, face to face), as the procedure codes are 30-minute, time-based codes. Rounding of time furnished is not allowed for 30-minute time-based codes. 

The procedure codes required by Medicare for the DSMT claim are: 

G0108 – DSMT, individual, per 30 minutes 

G0109 – DSMT, group (2 or more), per 30 minutes 

Referral Documentation Requirements 

Initial DSMT 

Medical necessity for initial DSMT services must be established via a written or e-referral for DSMT by the treating provider. The treating provider (who must also be an active Medicare provider or in opt out status) is the physician or qualified non-physician practitioner (nurse practitioner, physician assistant, clinical nurse specialist) who is managing the beneficiary’s diabetes. The provider must maintain a plan of diabetes care in the beneficiary’s medical record, and submit a referral documenting: 

  • That DSMT is needed. 
  • If DSMT is to be group or individual. 
  • If individual, one or more of the 3 conditions that warrant individual DSMT. A condition is not needed for FQHCs or RHCs, as only individual DSMT is payable. 
  • The number of initial hours to be furnished (10 hours, or fewer than 10 hours). 
  • The topics to be taught (i.e., all 10 topics or only specific topic(s), such as nutrition). 
  • The diagnosis or valid, ICD-10 diagnosis code. (For type 1 and type 2 diabetes, a 5-character primary diagnosis code of diabetes is required.) 
  • The signature of the referring provider. (A stamped signature is not allowed, but an e-signature in the EMR is allowed.) 
  • The NPI number of the referring provider. 
  • The beneficiary’s name. 
  • The date. 

Follow-up DSMT 

The treating provider must maintain a plan of diabetes care in the beneficiary’s medical record and submit a referral documenting: 

  • That follow-up DSMT is needed. 
  • The diagnosis or valid, ICD-10 diagnosis code. (For type 1 and type 2 diabetes, a 5-character primary diagnosis code of diabetes is required.) 
  • The signature of the referring provider. (A stamped signature is not allowed, but an e-signature in the EMR is allowed.) 
  • The NPI number of the referring provider. 
  • The beneficiary’s name. 
  • The date. 

Medicare Billing Provider Types and Related Information 

Billing providers who are authorized by statute are: 

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. 

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Tennessee Pharmacists Association

1732 Lebanon Pike Circle, Nashville, TN 37210
phone: 615-256-3023 fax: 615-255-3528
email: tpa@tnpharm.org