HCPCS Code Description
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
Modifier Description
GQ Via asynchronous telecommunications system
Place of Service Description
02 Telehealth: The location where health services and health related services are provided or received, through a telecommunication system.
PURPOSE
The Medicare Advantage Policy Guideline documents are generally used to support UnitedHealthcare Medicare Advantage claims processing activities and facilitate providers’ submission of accurate claims for the specified services.
Certified Providers
A designated certified provider bills for DSMT provided by an accredited DSMT program. C ertified providers must submit a copy of their accreditation certificate to the contractor. The statute states that a “certified provider” is a physician or other individual or entity designated by the Secretary that, in addition to providing outpatient selfmanagement training services, provides other items and services for which payment may be made under title XVIII,
and meets certain quality standards. The CMS is designating all providers and suppliers that bill Medicare for other individual services such as hospital outpatient departments, renal dialysis facilities, physicians and durable medical equipment suppliers as certified. All suppliers/providers who may bill for other Medicare services or items and who represent a DSMT program that is accredited as meeting quality standards can bill and receive payment for the entire DSMT program. Registered dietitians are eligible to bill on behalf of an entire DSMT program, as long as the provider has obtained a Medicare provider number. A dietitian may not be the sole provider of the DSMT service. There is an exception for rural areas. In a rural area, an individual who is qualified as a registered dietitian and as a certified diabetic educator who is currently certified by an organization approved by CMS may furnish training and is deemed to meet the multidisciplinary team requirement. C ertified providers may be asked to submit updated accreditation documents at any time or to submit outcome data to an organization designated by CMS.
Frequency of Training
The initial year for DSMT is the 12 month period following the initial date. Medicare will cover initial training that meets the following conditions:
• Is furnished to a beneficiary who has not previously received initial or follow-up training under HCPCS codes G0108 or G0109;
• Is furnished within a continuous 12-month period;
• Does not exceed a total of 10 hours (the 10 hours of training can be done in any combination of 1/2 hour increments);
• With the exception of 1 hour of individual training, training is usually furnished in a group setting, which can contain other patients besides Medicare beneficiaries, and;
• One hour of individual training may be used for any part of the training including insulin training.
Follow-Up Training
Medicare covers follow-up training under the following conditions:
• No more than 2 hours individual or group training per beneficiary per year;
• Group training consists of 2 to 20 individuals who need not all be Medicare beneficiaries;
• Follow-up training for subsequent years is based on a 12 month calendar after completion of the full 10 hours of initial training;
• Follow-up training is furnished in increments of no less than one-half hour; and
• The physician (or qualified non-physician practitioner) treating the beneficiary must document in the beneficiary's medical record that the beneficiary is a diabetic.
Coverage Requirements for Individual Training
Medicare covers training on an individual basis for a Medicare beneficiary under any of the following conditions:
• No group session is available within 2 months of the date the training is ordered;
• The beneficiary’s physician (or qualified non-physician practitioner) documents in the beneficiary’s medical record that the beneficiary has special needs resulting from conditions, such as severe vision, hearing or language limitations or other such special conditions as identified by the treating physician or non-physician practitioner, that will hinder effective participation in a group training session; or
• The physician orders additional insulin training.
• The need for individual training must be identified by the physician or non-physician practitioner in the referral.
Telehealth
Individual and group DSMT services may be paid as a Medicare telehealth service. Before 03-11-2016, this manual provision required that 1 hour of the 10 hour DSMT benefit’s initial training must be furnished in-person to allow for effective injection training. Because injection training is not always clinically indicated, we are revising this provision to permit all 10 hours of the initial training and the two (2) hours of annual follow-up training to be furnished via telehealth in those cases when injection training is not applicable. The in-person injection training, when provided, may be furnished through either individual or group DSMT services. By reporting place of service (POS) 02 or the –GT or –GQ modifier with HCPCS code G0108 (Diabetes outpatient self-management training services, individual, per 30 minutes) or G0109 (Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes), the distant site practitioner attests that the beneficiary has received or will receive 1 hour of in-person DSMT services for purposes of injection training when it is indicated during the year following the initial DSMT service or any calendar year’s 2 hours of follow-up training.
As specified in the Medicare Benefit Policy Manual, chapter 15, section 300.2, individual DSMT services may be furnished by a physician, individual, and group DMST services may be furnished by a physician, other individual, or entity that furnishes other items or services for which direct Medicare payment may be made and that submits necessary documentation to, and is accredited by, a national accreditation organization approved by CMS. However, consistent with the statutory requirements of section 1834(m)(1) of the Act, as provided in 42 C FR 410.78(b)(1) and (b)(2) and stated in section 190.6 of this chapter, Medicare telehealth services, including individual and group DSMT services furnished as a telehealth service, could only be furnished by a licensed PA, NP, CNS, CNM , clinical psychologist, clinical social worker, or registered dietitian or nutrition professional, as applicable.
For Medicare payment to occur, interactive audio and video telecommunications must be used, permitting real-time communication between the distant site physician or practitioner and the Medicare beneficiary. As a condition of payment, the patient must be present and participating in the telehealth visit.
DMEPOS Suppliers
The DMEPOS suppliers are reimbursed for diabetes training through local carriers. In order to file claims for DSMT, a DMEPOS supplier must be enrolled in the Medicare program with the National Supplier Clearinghouse (NSC ). The supplier must also meet the quality standards of a CMS-approved national accreditation organization as stated above. DMEPOS suppliers must obtain a provider number from the local carrier in order to bill for DSMT.
The carrier requires the appropriate completed form, along with an accreditation certificate as part of the provider application process. After it has been determined that the quality standards are met, a billing number is assigned to the supplier. Once a supplier has received a National Provider Identification (NPI) number, the supplier can begin receiving reimbursement for this service.
Diabetes Education
Yes. In order for a client to participate in the diabetes education program, a licensed primary health care provider must refer the client to a program for diabetes education. Hospitals must be approved by the Washington State Department of Health (DOH) as a diabetes education provider.
For diabetes education services provided in a hospital outpatient setting, the provider must:
• Bill using revenue code 0942.
• Provide a minimum of 30 minutes of education/management per session.
Note: Services provided in an outpatient hospital department or hospital-based clinic must be billed on a UB-04 claim form. Services provided in a non-hospital based clinic or a physician’s office must be billed on a CMS-1500 claim form.
Note: The agency requires authorized hospital outpatient diabetes education programs to bill with revenue code 0942. Claims submitted using HCPCS codes G0108 and G0109 will be denied.
Denial reasons
Providers should be aware that MACs will return claims if you append demo code 85, and:
• You are not on the CEC participant provider list with a telehealth record type; or
• DOS “from date” is prior to your telehealth effective date, or
• DOS “from date” is after your telehealth termination date, or
• The DOS “from date” is prior to the beneficiary’s effective date; or
• The DOS “from date” is after the beneficiary’s termination date, or
• The DOS “from date” is more than 90 days after the beneficiary’s termination date; or
• The beneficiary was not aligned to the same ESCO with which you are participating, as identifi ed by ESCO ID; or
• The claim is for Part A and the TOB is other than 12X, 13X, 22X, 23X, 71X, 72X, 76X, 77X, and 85X,
• Other, non-telehealth services are billed on the same claim. In these cases, none of the services on the claim are processed.
In returning Part B claims, your MAC will use the following messaging:
• Claims Adjustment Reason Code (CARC) 16: (Claim/service lacks information or has submission/billing error(s) which is needed for adjudication) and
• Remittance Advice Remark Code (RARC) N763 (The demonstration code is not appropriate for this claim; resubmit without a demonstration code.)
• Group Code: CO (Contractual Obligation)
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