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DSMT Toolkit

Chapter 5. Medicare Billing Detail

Medicare, under its Fee for Service (FFS) payment system (“original Medicare”) reimburses 80% of the cost of the DSMT benefit. Beneficiaries pay coinsurance of 20% of the Medicare approved rate for DSMT. Sites that are providing DSMT in partnership with a Medicare FFS provider should work closely with their partner to understand what the beneficiary pays, the types of coverage that each beneficiary has and how the coverage affects DSMT billing.

NOTE: Those AAAs whose partner is a Federally Qualified Health Center operate under different billing and payment rules, which are described in the section titled “Working with FQHCs.”

To bill the Medicare Part B program for DSMT, a number of key elements must be in place.

The beneficiary must have:

  • A diabetes diagnosis
  • A written referral for DSMT, provided by a qualified provider
  • Part B benefits under “original Medicare” (i.e., not benefits as a member of a Medicare Advantage Plan)
  • Met their annual deductible or have Medicaid or other health insurance coverage (such as a “Medigap” policy) that pays the deductible.

The AAA’s DSMT program must have:

  • Accreditation from a CMS-recognized organization—currently either AADE or ADA.
  • A partnership with a Medicare provider that is able to bill the Medicare program, or be a Medicare provider in its own right.
  • Recognition by CMS of the accredited Medicare Provider location where the DSMT will be provided.

The AAA’s Medicare provider partner generally will be responsible for:

  • maintaining documentation of the beneficiary’s diabetes diagnosis in his or her medical record,
  • verifying a beneficiary’s Part B coverage for DSMT,
  • verifying that the beneficiary has already met the annual deductible, and
  • determining whether the beneficiary has Medicare supplemental coverage through Medicaid or a private insurance policy.
  • collecting the 20% coinsurance from the beneficiary or supplemental coverage, as applicable

When services are provided at a Federally Qualified Health Center (FQHC), the beneficiary does not need to have already met his/her Part B deductible. Therefore, the Medicare program will pay the full reimbursement amount to the FQHC even if the beneficiary has not met the Medicare deductible.

NOTE: The MNT benefit does not require the beneficiary to pay 20% coinsurance, so Medicare reimburses the provider at 100% of the approved rate.

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HCPS Coding

DSMT and MNT are billed to Medicare using the Healthcare Common Procedure Coding System (HCPCS) billing codes, as shown in the tables below.

Initial Calendar Year DSMT (2013 Fee Schedule)

Code Base Reimbursement Unit Price Allowable Units per Annum Total Reimbursment
G0108 $52.06 Individual training in 30 minute increments 1 hour (2 units) $104.12
G0109 $13.95 Group training in 30 minute increments 9 hours (18 units) $251.11
  $355.23**

** Total of 10 hours of DSMT services will be reimbursed at this level per Medicare beneficiary

Initial Calendar Year MNT (2013 Fee Schedule)

Code Base Reimbursement Unit Price Allowable Units per Annum Total Reimbursment
97802 $35.38 Initial MNT, individual, in 15 minute increments 1 hour (4 units) $141.52
97803 $30.62 Follow up individual training in 15 minute increments 2 hours (8 units) $244.96
97804 $15.65 Follow up Group MNT, in 30 minute increments 2 hours (4 units) $62.60
  $204.12**

** Total of 3 hours of MNT (1 hour initial and 2 hour group follow-up) will reimburse at this level per Medicare beneficiary.

Please note that reimbursement amounts vary by region and are updated each calendar year and published in the CMS annual Physician Fee Schedule. The fees below represent the base reimbursement level, prior to the application of the regional variation factor for payment. Therefore, the amounts may be higher or lower than applicable in your region.

The dollar amounts in the charts throughout this guide are used to establish a baseline. The Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule shows regional specific rates.

Find current CMS rates on the CMS website.

Post Initial Calendar Year Training

Code Base Reimbursement Unit Price Allowable Units per Annum Total Reimbursment
DSMT
G0108 $52.06 Individual training in 30 minute increments 1 hour (2 units) $104.12
G0109 $13.95 Group training in 30 minute increments 1 hours (2 units) $27.90
MNT
97803 $30.62 Follow up individual training in 15 minute increments 2 hours (8 units) $244.96

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Last Modified: 12/31/1600