MDPP: When Patients Lose, Providers Win
Follow billing guidelines to ensure proper payment for this incentive payment model.
The Medicare Diabetes Prevention Program (MDPP) expanded model is a structured behavior change intervention that aims to prevent the onset of type 2 diabetes among Medicare beneficiaries with an indication of pre-diabetes. The clinical intervention consists of a minimum of 16 intensive “core” sessions of a CDC-approved curriculum furnished over six months in a group-based, classroom-style setting that provides practical training in long-term dietary change, increased physical activity, and behavior change strategies for weight control. Follow-up meetings are then furnished monthly to ensure participants maintain health behaviors learned in group sessions.
Payment is tied to:
- Number of core sessions attended;
- Weight loss of 5 to 9 percent of baseline weight; and
- Maintenance sessions if 5 percent or greater weight loss is maintained.
The 2018 Physician Fee Schedule final rule established that MDPP services may begin being furnished on April 1, 2018. Proper billing of MDPP services comes down to asking the right questions.
Is Your Provider an MDPP Supplier?
A provider must separately enroll in Medicare as an MDPP supplier to bill for MDPP services; and MDPP suppliers may only bill Medicare for MDPP services. A provider enrolled as an MDPP supplier and another Medicare provider type must bill MDPP services and non-MDPP services on separate claim forms.
There are two steps to becoming an MDPP supplier:
- Achieve CDC recognition; and
- Apply to become a supplier.
MDPP supplier requirements include:
- Attest to attendance/weight loss on claims
- Maintain records of attendance/weight loss for auditing purposes
Is the Patient Eligible for MDPP Services?
Verify patient eligibility before billing Medicare for MDPP core services. There are four ways you can do this:
- MAC online provider portal
- MAC phone verification
- HIPAA Eligibility Transaction System (HETS)
- Billing agency, clearinghouse, or software vendor
What is HETS?
The HIPAA Eligibility Transaction System, or HETS, allows MDPP suppliers to check Medicare patient eligibility data in real time. Use HETS to submit HIPAA compliant 270 eligibility request files over a secure connection and receive 271 response files.
Starting Dec. 8, HETS returns MDPP usage information. The HETS Medicare beneficiary eligibility response (271) includes HCPCS Level II codes for MDPP services if the National Provider Identifier (NPI) on the eligibility inquiry (270) belongs to a Medicare enrolled MDPP supplier, or if it includes the service type code CQ Case management.
With the latest release, HETS 270/271 will also return updated 2019 deductible, co-payment, and coinsurance liabilities in the 271 benefit response, when appropriate. All currently supported HCPCS Level II codes will continue to function until Dec. 31, 2018.
What Are the Billing and Payment Rules for MDPP Services?
There are many rules you must follow to ensure proper payment for MDPP services. Per a Centers for Medicare & Medicaid Services (CMS) MDPP Billing and Claims Fact Sheet:
- MDPP suppliers must submit a claim for either attendance at the first core session or a bridge payment before submitting claims for any other MDPP services.
- Submit each MDPP HCPCS Level II G code once per eligible beneficiary, except for the bridge payment and a non-payable code (such as G9891 to report attendance at sessions that are not associated with a performance goal).
- Eligible MDPP beneficiaries are not required to pay anything out of pocket for MDPP services.
- MDPP suppliers can include multiple MDPP HCPCS Level II codes on a claim for a single beneficiary.
- During a core maintenance session interval, MDPP suppliers can submit a claim if the patient attends two sessions and has 5 percent weight loss or attends two sessions and does not have 5 percent weight loss; but the supplier may not submit claims for both. Do not submit claims until a performance goal is met.
- MDPP suppliers can submit a claim when a patient first loses 5 percent of weight from baseline only during months 0-12 of the MDPP services period or 9 percent of weight from baseline in months 0-24 of the MDPP services period.
If a patient changes MDPP suppliers and two suppliers submit a claim for furnishing the same service to the same patient, the supplier who submits the claim first will be paid. If the patient is changing MDPP suppliers, identify where they are in their service timeline by obtaining their records from the other MDPP supplier. You can bill a bridge payment for the first session if your MDPP did not furnish the patient’s core session.
How Should I Submit Claims?
Use the 837P or CMS-1500 to submit MDPP clsims to your Medicare Administrative Contractor or billing agent. In addition to the usual patient information, place of service, and supporting diagnosis code(s), include the the following information on each claim form:
- Demo code 82 in block 19 of the CMS-1500 or its electronic equivalent.
- The appropriate G code(s) with the corresponding session date of service and rendering MDPP coach’s NPI.
- The virtual modifier VM appended to any G code associated with a session that was furnished as a virtual makeup session.
- The MDPP supplier organizational NPI .
Refer to the CMS Quick Reference Guide to Payment and Billing for a snapshot of the MDPP payment structure and list of G codes.
Where Can I Learn More About MDPP?
CMS is hosting a webinar, Medicare Diabetes Prevention Program Expanded Model – Enrollment Tutorial, on Jan. 9, 2019, from 11 am to 12 pm EST. You can register here. You may want to review CMS’s user guide and prepare questions before the webinar.
Be sure to review annual payment updates. MLN Matters article number MM10970 provides updates to 2019 MDPP payment rates.
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