Diabetes is now the fastest-growing chronic disease globally and is the costliest chronic condition in the U.S., as reported by the American Diabetes Association (ADA). The Medicare Diabetes Prevention Program (MDPP) is a free, two-year program that helps Medicare beneficiaries with prediabetes prevent or delay type 2 diabetes. The program is part of the CDC’s National Diabetes Prevention Program. Medicare pays organizations and providers enrolled as MDPP suppliers for providing MDPP services to eligible beneficiaries. As a medical billing and coding company, we are well aware that documentation and billing for MDPP services requires careful attention. That’s because these services are billed differently than traditional fee-for service (FFS) Medicare services. MDPP services for eligible beneficiaries are billed based on a performance-based payment structure, specifically attendance and weight loss.
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Medicare Expands Access to Diabetes Screening Services
The MDPP program includes:
- Core sessions: 16 weekly group sessions that provide training on healthy eating, physical activity, and weight control
- Monthly meetings: Less intensive meetings that participants attend after the core sessions
- Support: A specially trained coach and support from other participants
The 2024 Medicare Physician Fee Schedule introduced several changes aimed at reducing barriers and enhancing beneficiaries’ access to diabetes screening and treatment services. One important update, according to Dr. Kate Kirley, AMA’s director of chronic disease prevention and programs, is that Medicare now covers the hemoglobin A1C test for screening purposes (www.ama-assn.org).
Many physicians prefer the hemoglobin A1c test for diabetes screening, but ensuring that their patients have insurance coverage for it has been challenging, according to Dr. Kirley. Previously, Medicare covered the hemoglobin A1c test solely for monitoring patients with type 2 diabetes, but recent updates now permit its use for screening prediabetes and type 2 diabetes.
According to the American Medical Association (AMA), coverage for the A1c test is expected to lead to more screenings and earlier diagnoses, which will lead to more referrals to the MDPP.
Billing and Coding MDPP Services – Key Points
Organizations must be separately enrolled in Medicare as an MDPP supplier to bill for MDPP services. MDPP includes three different session types: cores sessions, core maintenance sessions and ongoing maintenance sessions.
CMS’ MDPP Billing and Claims Fact Sheet provides billing guidance and codes for MDPP suppliers:
HCPCS G-Codes for MDPP Services
Core Sessions
G9873 MDPP beneficiary attended the first MDPP core session.
G9874 MDPP beneficiary attendeda total of 4 MDPP core sessions.
G9875 MDPP beneficiary attendeda total of 9 MDPP core sessions.
Core Maintenance Sessions
G9882 MDPP beneficiary attended 2 MDPP ongoing maintenance sessions in months 13-15, and achieved the 5% weight loss from his/her baseline weight during the interval.
G9883 MDPP beneficiary attended 2 MDPP ongoing maintenance sessions in months 16-18, and achieved the 5% weight loss from his/her baseline weight during the interval.
G9884 MDPP beneficiary attended 2 MDPP ongoing maintenance sessions in months 19-21, and achieved the 5% weight loss from his/her baseline weight during the interval.
G9885 MDPP beneficiary attended 2 MDPP ongoing maintenance sessions in months 22-24, and achieved the 5% weight loss from his/her baseline weight during the interval.
Additional Codes
G9880 MDPP beneficiary achieved at least 5% weight loss from his/her baseline weight in months 1–12. (one-time payment)
G9881 MDPP beneficiary achieved at least 9% weight loss from his/her baseline weight in months 1–24. (one-time payment)
G9890 Bridge Payment: A one-time payment for the first MDPP core session, core maintenance session, or ongoing maintenance session furnished by an MDPP supplier to an MDPP beneficiary during months 1–24.
G9891 MDPP session reported as a line item on a claim for MDPP services. (non-payable code)
CMS’ Billing Guidelines
- The Medicare payment structure is based on performance and encourages positive health outcomes for beneficiaries, such as attendance and weight loss
- As a provider in the MDPP, you must submit a claim for either attendance at the initial core session or a bridge payment before claiming any other MDPP services.
- Each MDPP HCPCS code can only be submitted once per eligible beneficiary, with the exception of the non-payable code used for reporting core sessions 5-8.
- During a core maintenance session interval, a provider can submit a claim if the beneficiary attends two sessions and either achieves a 5% weight loss or does not; however, claims cannot be submitted for both scenarios.
- You may submit a claim for a beneficiary’s first 5% weight loss from baseline only during the first 12 months of the MDPP service period.
- Claims can be submitted for a first-time 9% weight loss from baseline within the 0-24 months of the MDPP service period.
CMS outlines several key points that MDPP service providers should keep in mind:
- Use HCPCS G-codes when submitting claims to Medicare for payment. MDPP HCPCS G-codes can only be submitted once per eligible beneficiary, except for G9891.
- Claims for the initial session (G9873) or bridge payment (G9890) must be submitted before any other claims will be processed.
- Claims should be filed when a performance goal is achieved, such as attendance or weight loss.
- If a beneficiary changes suppliers, the new supplier may receive a bridge payment (G9890) for the first MDPP session provided to that beneficiary. Multiple suppliers can claim the bridge payment for the same beneficiary.
Leverage Expert Support
Understanding the key billing practices and payment rules for MDPP services is essential for providers to ensure compliance and maximize reimbursement. By navigating these complexities effectively, healthcare professionals can enhance their operational efficiency and focus on delivering quality care. Outsourcing medical billing can streamline this process, allowing providers to leverage specialized expertise and resources, ultimately leading to improved reimbursement and better patient experiences.
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