(Medicare Benefit Policy Manual)

 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.   *When a claim contains a DSMT HCPCS code and the associated units cause the total time for any follow -up year to exceed 2 hours, a CWF error will set.  300.4 - Coverage Requirements for Individual Training  (Rev. 72, Issued:  05- 25-07; Effective:  07 -01-07; Implementation:  07- 02-07)  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 beneficiarys physician (or qualified non -physician practitioner) documents in the beneficiarys 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.   NOTE:  If individual training has been provided to a Medicare beneficiary and subsequently the A/B MAC (A) or (B) determines that training should have been provided in a group, A/B MACs (A) and (B) down- code the reimbursement from individual to the group level a nd provider education would be the appropriate actions instead of denying the service as billed.  300.4.1  Incident -To Provision  (Rev. 13, 05- 13-04)  The incident to requirements of section 1861(s)(2)(A) of the Social Security Act do not apply to DSMT services.  Section 1861 (s)(2)(S) of the Act authorizes DSMT in a stand alone provision. DSMT services are covered only if the physician or qualified non-  physician practitioner who is managing the beneficiarys diabetic condition certifies that such services are needed and refers the patient to the DSMT program.  The referral must be done under a comprehensive plan of care related to the beneficiarys di abetic condition.  Training may be furnished by a physician, individual, or entity that meets the following conditions:    Furnishes other services for which direct Medicare payment may be made;    May properly receive Medicare payment under 42CFR 424.73 or 424.80 which set forth prohibitions on assignment and reassignment of claims;    Submits necessary documentation to, and is accredited by, an accreditation organization approved by CMS under 42CFR 410.142 to meet one of the sets of quality standards described in 42 CFR 410.144; and  Provides documentation to CMS, as requested, including diabetes outcome measurements set forth at CFR 410.146.  Any certified providers or suppliers that provide other individual items or services under Medicare that meet CMSs quality standards and meet the conditions for CMS approval pursuant to 42 CFR 410.145, may receive reimbursement for diabetes training.  Ent ities are more likely than individuals to bill for DSMT services.  These certified providers must be currently receiving payment for other Medicare services.   300.5 - Payment for DSMT  (Rev. 72, Issued:  05- 25-07; Effective:  07 -01-07; Implementation:  07- 02-07)  Payment for DSMT may only be made to any provider that bills Medicare for other individual Medicare services and may be made only for training sessions actually attended by the beneficiary and documented on attendance sheets.   See Pub. 100- 04, chapter 18, section 120 for specific payment information for physicians and all provider types.   300.5.1 - Special Claims Processing Instructions for A/B MACs (A)  (Rev. 24, Issued: 10- 29-04, Effective: 01 -01-05, Implementation: 01- 03-05)   Coding and Payment Requirements   The provider bills for DSMT on Form CMS -1450 or its electronic equivalent.  The cost of the service is billed under revenue code 942 in FL 42 Revenue Code.  The provider will report HCPCS codes G0108 or G0109 in FL 44 HCPCS/Rates.  The definition of the HCPCS code used should be entered in FL 43 Description.    Applicable Bill Types   The appropriate bill types are 12x, 22x, 13x, 34x (can be billed if service is outside of the treatment plan), 72x, 74x, 75x, 83x and 85x.  310  Kidney Disease Patient Education Services  (Rev. 117; Issued:  12- 18-09; Effective Date:  01 -01-10; Implementation Date:  04-05-10)  By definition, chronic kidney disease (CKD) is kidney damage for 3 months or longer, regardless of the cause of kidney damage.  CKD typically evolves over a long period of time and patients may not have symptoms until significant, possibly irreversible, da mage has been done.  Complications can develop from kidneys that do not function properly, such as high blood pressure, anemia, and weak bones.  When CKD progresses, it may lead to kidney failure, which requires artificial means to perform kidney functions  (dialysis) or a kidney transplant to maintain life.   Patients can be classified into 5 stages based on their glomerular filtration rate (GFR, how quickly blood is filtered through the kidneys), with stage I having kidney damage with normal or increased GFR to stage V with kidney failure, also called end- stage renal disease (ESRD).  Once patients with CKD are identified, treatment is available to help prevent complications of decreased kidney function, slow the progression of kidney disease, and reduce the risk of other diseases such as heart disease.   Beneficiaries with CKD may benefit from kidney disease education (KDE) interventions due to the large amount of medical information that could affect patient outcomes, including the increasing emphasis on self -care and patients desire for informed, autonomous decision- making.  Pre -dialysis education can help patients achieve better understanding of their illness, dialysis modality options, and may help delay the need for dialysis.  Education interventions should be patient -centered, encourage collaboration , offer support to the patient, and be delivered consistently.   Effective for claims with dates of service on and after January 1, 2010, Section 152(b) of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) covers KDE services under Medicare Part B.  KDE services are designed to provide beneficiari es with Stage IV CKD comprehensive information regarding: the management of comorbidities, including delaying the need for dialysis; prevention of uremic complications; all therapeutic options (each option for renal replacement therapy, dialysis access opt ions, and transplantation); ensuring that the beneficiary has opportunities to actively participate in his/her choice of therapy; and that the services be tailored to meet the beneficiarys needs.   Regulations for KDE services were established at 42 CFR 410.48.  Claims processing instructions and billing requirements can be found in Pub. 100- 04, Medicare Claims Processing Manual, Chapter 32  Billing Requirements for Special Services, Section 20.  310.1 - Beneficiaries Eligible for Coverage  (Rev. 117; Issued:  12- 18-09; Effective Date:  01 -01-10; Implementation Date:  04-05-10)  Medicare Part B covers outpatient, face -to-face KDE services for a beneficiary that:    is diagnosed with Stage IV CKD, using the Modification of Diet in Renal Disease (MDRD) Study formula (severe decrease in GFR, GFR value of 15 -29 mL/min/1.73 m2), and    obtains a referral from the physician managing the beneficiarys kidney condition. The referral should be documented in the beneficiarys medical records.   310.2 - Qualified Person  (Rev. 117; Issued:  12- 18-09; Effective Date:  01 -01-10; Implementation Date:  04 -05-10)  Medicare Part B covers KDE services provided by a qualified person, meaning a:    physician (as defined in section 30 of this chapter),   physician assistant, nurse practitioner, or clinical nurse specialist (as defined in sections 190, 200, and 210 of this chapter),    hospital, critical access hospital (CAH), skilled nursing facility (SNF), comprehensive outpatient rehabilitation facility (CORF), home health agency (HHA), or hospice, if the KDE services are provided in a rural area (using the actual geographic location core based statistical area (CBSA) to identify facilities located in  rural areas), or    hospital or CAH that is treated as being rural (was reclassified from urban to rural status per 42 CFR 412.103).  NOTE:   The incident to requirements at section 1861(s)(2)(A) of the Social Security Act (the Act) do not apply to KDE services.  The following providers are not qualified persons and are excluded from furnishing KDE services:    A hospital, CAH, SNF, CORF, HHA, or hospice located outside of a rural area (using the actual geographic location CBSA to identify facilities located outside of a rural area), unless the services are furnished by a hospital or CAH that is treated as being in a rural area; and    Renal dialysis facilities.   310.3 - Limitations for Coverage  (Rev. 194, Issued: 09- 03-14, Effective: Upon Implementation of ICD -10, Implementation: Upon Implementation of ICD -10)  Medicare Part B covers KDE services:    Up to six (6) sessions as a beneficiary lifetime maximum.  A session is 1 hour.  In order to bill for a session, a session must be at least 31 minutes in duration.  A session that lasts at least 31 minutes, but less than 1 hour still constitutes 1 session.    On an individual basis or in group settings; if the services are provided in a group setting, a group consists of 2 to 20 individuals who need not all be Medicare beneficiaries .  NOTE:   Two HCPCS codes were created for this benefit and one or the other must be present, along with the appropriate ICD diagnosis codes.   The diagnosis codes are:    ICD-9-CM -  code 585.4 (chronic kidney disease, Stage IV (severe)), or    ICD-10-CM -  code N18.4 (chronic kidney disease, Stage IV).   The HCPCS  codes are:    G0420:  Face -to-face educational services related to the care of chronic kidney disease; individual, per session, per one hour    G0421:   Face -to-face educational services related to the care of chronic kidney disease; group, per session, per one hour   310.4  Standards for Content  (Rev. 117; Issued:  12- 18-09; Effective Date:  01 -01-10; Implementation Date:  04-05-10)  Medicare Part B covers KDE services, provided by a qualified person, which provide comprehensive information regarding:   A. The management of comorbidities, including delaying the need for dialysis, which includes, but is not limited to, the following topics:    Prevention and treatment of cardiovascular disease,   Prevention and treatment of diabetes,   Hypertension management,  Anemia management,   Bone disease and disorders of calcium and phosphorus metabolism management,  Symptomatic neuropathy management, and   Impairments in functioning and well -being.   B. Prevention of uremic complications, which includes, but is not limited to, the following topics:    Information on how the kidneys work and what happens when the kidneys fail,  Understanding if remaining kidney function can be protected, preventing disease progression, and realistic chances of survival,   Diet and fluid restrictions, and   Medication review, including how each medication works, possible side effects and minimization of side effects, the importance of compliance, and informed decision making if the patient decides not to take a specific drug.   C. Therapeutic options, treatment modalities and settings, advantages and disadvantages of each treatment option, and how the treatments replace the kidney, including, but not limited to, the following topics:    Hemodialysis, both at home and in- facility;  Peritoneal dialysis (PD), including intermittent PD, continuous ambulatory PD, and continuous cycling PD, both at home and in- facility;  All dialysis access options for hemodialysis and peritoneal dialysis; and   Transplantation.   D. Opportunities for beneficiaries to actively participate in the choice of therapy and be tailored to meet the needs of the individual beneficiary involved, which includes, but is not limited to, the following topics: