Last year, we told you that under the 1997 Balanced Budget Act (BBA), Medicare would soon be covering diabetes self-management education and training under certain conditions (see “An Ounce of Prevention,” April 1998). Now, Medicare has worked out the details of this provision, and here's what you need to know to bill for this service.

The right trainer

First, the physician managing the patient's diabetes must order the training sessions and certify that the patient needs them as part of a comprehensive plan of care related to the condition. Additionally, under BBA, the training must come from “a certified provider,” which Medicare defines as a physician, other individual or entity paid under Medicare's physician fee schedule who meets the National Diabetes Advisory Board (NDAB) standards. To demonstrate that you are a certified provider, you must send your Medicare carrier an Education Recognition Program (ERP) certificate from the American Diabetes Association (ADA) before submitting any claims for this service. If you're interested in earning an ERP certificate or obtaining a copy of the NDAB standards, contact the ADA at 888-232-0822. You may also be able to get a copy of the standards from your Medicare carrier.

Certified diabetic educators and dietitians employed by physicians or entities that meet the ADA standards also may provide diabetes self-management training in out-patient settings. But since these individuals aren't paid according to the physician fee schedule and therefore aren't “certified providers” as defined by Medicare, carriers can only make payments to their employers under the “incident to” provisions. If a physician provides the training but isn't certified by the ADA, Medicare will deny the claim and the beneficiary will be liable for payment.

The right coding

When billing Medicare for this service, use one of these HCPCS codes (which are valid for dates of service on or after July 1, 1998):

• G0108, “Diabetes outpatient self-management training services, individual session, per 60 minutes of training”;

• G0109, “Diabetes outpatient self-management training services, group session, per individual, per 60 minutes of training.”

Medicare expects that you would normally provide this training in group sessions, but it will allow individual training sessions if the physician decides they are medically necessary (for example, if the patient is hearing-or sight-impaired). Like other services paid under the Medicare physician fee schedule, the payment allowances for these codes vary geographically, so check with your carrier for the allowed amount in your area.

Also, note that you need to bill diabetic training sessions in one-hour increments; do not round up or down. For example, if a session lasts 90 minutes, you can only bill one hour for that session, but you can count the 30 extra minutes toward a future session. Generally, Medicare considers that it would not be medically necessary for a patient with diabetes to receive more than 10 hours of service for initial training in self-management.