From April 1, 2018, the Centers for Medicare and Medicaid Services (CMS) have expanded its Medicare Diabetes Prevention Program (MDPP) nationwide, which will now enroll both traditional healthcare providers and community-based organizations as Medicare suppliers of health behavior change services. According to CMS Administrator Seema Verma, “This innovative model promotes patient-centered care and continues to test market-driven reforms to drive quality of care and improve outcomes for America’s seniors, more than a quarter of whom have type 2 diabetes.” As medical billing service providers know, documentation and coding for Medicare Diabetes Prevention Program requires much attention as well as awareness.

Medicare pays organizations and providers enrolled as MDPP suppliers for furnishing MDPP services to eligible beneficiaries using a performance-based payment structure that incentivizes positive health outcomes for beneficiaries.

Billed differently than traditional fee-for service (FFS) Medicare services, MDPP services should also include insurance eligibility verification before billing. Eligibility verification can be done via MAC online provider portal, MAC phone verification, HIPAA Eligibility Transaction System (HETS) or through an experienced medical billing company or software vendor.

CMS’ MDPP Billing and Claims Fact Sheet provides guidelines on proper MDPP billing practices and payment rules which include:

  • Organizations or healthcare providers must be separately enrolled in Medicare as an MDPP supplier to bill for these services.
  • Suppliers must submit a claim for either attendance at the first core session or a bridge payment before you submit claims for any other MDPP services.
  • Except for the bridge payment and a non-payable code, submit each MDPP HCPCS code only once per eligible beneficiary.
  • Eligible MDPP beneficiaries do not have to pay anything out of pocket for MDPP services.
  • Suppliers must accept Medicare’s payment for MDPP services as payment in full and cannot bill or collect any amount from the beneficiary.
  • Suppliers can include multiple MDPP HCPCS codes on a claim for a single beneficiary.
  • If the patient is changing MDPP suppliers, identify where they are in their service timeline by obtaining their records from the other MDPP supplier.
  • A bridge payment can be billed for the first session if the supplier’s MDPP did not furnish the patient’s core session.

All claims must be submitted to supplier’s Medicare Administrative Contractors (MACs) directly or to a billing agent. While submitting the claim, make sure to include the information such as – demo code 82 in block 19 of the CMS-1500 or its electronic equivalent, appropriate G code(s) with the corresponding session date of service and rendering MDPP coach’s National Provider Identifier (NPI), virtual modifier VM appended to any G code associated with a session that was furnished as a virtual makeup session as well as MDPP supplier organizational NPI.

Certain G-codes that can be used include:

  • G9874 MDPP beneficiary attended a total of 4 MDPP core sessions
  • G9875 MDPP beneficiary attended a total of 9 MDPP core sessions
  • G9876 MDPP beneficiary attended 2 MDPP core maintenance sessions in months 7-9
  • G9877 MDPP beneficiary attended 2 MDPP core maintenance sessions in months 10-12
  • G9878 MDPP beneficiary attended 2 MDPP core maintenance sessions in months 7-9, and achieved the 5% weight loss from his/her baseline weight (Use G9878 or G9876)
  • G9879 MDPP beneficiary attended 2 MDPP core maintenance sessions in months 10-12, and achieved the 5% weight loss from his/her baseline weight (Use G9879 or G9877)

MDPP HCPCS G-codes may be used only one time per eligible beneficiary (except for G9890 and G9891) and each HCPCS G-code should be listed with the corresponding session date of service and rendering coach NPI. Medical coding outsourcing to a professional billing agency helps in meeting any such billing requirements with better accuracy.