Medicare Diabetes Prevention Program: Coding Pre-Diabetes Services
A new Medicare program aims to reduce the risk of type 2 diabetes (T2DM) in patients 60 and older by 71 percent. The goal of the Medicare Diabetes Prevention Program (MDPP), rolled out last year by the Centers for Medicare & Medicaid Services (CMS), is to help patients achieve at least 5 percent weight loss.
Obesity poses a clinically significant risk of developing T2DM. So, by screening Medicare patients at risk of prediabetes and referring them to the MDPP, a behavioral change intervention, T2DM can be delayed, if not prevented.
Are You at Risk for Type 2 Diabetes?
Prediabetes is a serious condition that affects roughly half of all adults age 65 and older. Patients with prediabetes have higher than normal blood sugar levels, but not high enough for a diagnosis of type 2 diabetes. Fortunately, health behavioral changes can often prevent the onset of T2DM.
The Diabetes Prevention Program study funded by the NIH found that lifestyle changes resulting in modest weight loss resulted in a 58 percent reduction in the incidence of T2DM.
Diabetes affects one in four Americans aged 65 or older with an estimated two-fold increase in prevalence projected for all U.S. adults (ages 18-79) by 2050 if current trends continue, according to CMS. This disease poses a significant health threat coupled with an astronomical financial burden. Medicare spent an estimated $42 billion more in 2016 alone on beneficiaries with diabetes than it would have spent if those beneficiaries did not have diabetes.
What is MDPP All About?
The MDPP is an evidence-based, structured health behavior change program comprised of a minimum of 16 rigorous core sessions given over six months in a group-based, classroom-style setting. These structured sessions with a coach use a Centers for Disease Control and Prevention (CDC)-approved curriculum that provides training in dietary changes, increased physical activity, and strategies for weight control. Following the completion of the core sessions, beneficiaries may be eligible for additional monthly meetings to help ensure the maintenance of healthy behaviors.
As of April 1, 2018, eligible beneficiaries have coverage of MDPP services with no cost-sharing through Medicare-enrolled MDPP suppliers. Coverage includes 12 months of core sessions for beneficiaries with prediabetes, and an additional 12 months of ongoing maintenance sessions for participants who meet weight loss and attendance goals.
Eligible Medicare Patients:
- Are enrolled in Medicare Part B with prediabetes and meet other criteria
- Meet 1 of the following 3 blood test requirements within 12 months of the first core session:
- Hemoglobin A1c test with a value of 5.7-6.4 percent
- Fasting plasma glucose test with a value of 110-125 mg/dl
- Oral glucose tolerance test with a value of 140-199 mg/dl
- Have a body mass index (BMI) of at least 25 (or 23 if the patient self-identifies as Asian)
- Have NO previous diagnosis of type 1 or type 2 diabetes (other than gestational diabetes)
- Do not have end-stage renal disease (ESRD)
- Have never received MDPP services before
Successful patient outcomes include a reduced or delayed risk of developing T2DM, feeling healthier and more energized, and improved self-confidence and quality of life – all goals of value-based medicine.
Screen, Test, Refer
Providers need to monitor BMI and blood glucose to identify patients at risk of prediabetes. Blood tests should be ordered for any at-risk patients who could qualify for MDPP services. Eligible patients should be provided education on MDPP services and given a referral to a Medicare-enrolled MDPP supplier.
How Do I Bill for MDPP Services?
Bill Medicare for services furnished on or after April 1, 2018, using the HCPCS Level II G codes found on page 53289 of the CY 2018 final rule. Providers may report the MDPP HCPCS Level II G codes only one time per eligible patient (except for G9890 and G9891). You must submit the initial session (G9873) or bridge payment (G9890) claim before any other claims will be paid. MDPP suppliers receive performance-based payments through the CMS claims system.
CMS broke down the MDPP payment structure and corresponding HCPCS Level II G codes in their MDPP Quick Reference Guide to Payment and Billing; below is the depiction of the payment structure and associated HCPCS G-codes from this guide.