Coding and Payment of DSMT Services (Rev. 1255, 07-02-07)

by  Jared Staheli
July 6th, 2015

The following HCPCS codes are used to report DSMT:

G0108 - Diabetes outpatient self-management training services, individual, per 30 minutes.

G0109 - Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes.

The type of service for these codes is 1.

Payment to physicians and providers for outpatient DSMT is made as follows:

Type of Facility Payment Method Type of Bill
Physician (billed to the carrier) MPFS NA
Hospitals subject to OPPS MPFS 12X, 13X
Method I and Method II Critical Access Hospitals (CAHs) (technical services) 101% of reasonable cost 12X and 85X
Indian Health Service (IHS) providers billing hospital outpatient Part B OMB-approved outpatient per visit all inclusive rate (AIR) 13X
IHS providers billing inpatient Part B All-inclusive inpatient ancillary per diem rate 12X
IHS CAHs billing outpatient Part B 101% of the allinclusive facility specific per visit rate 85X
IHS CAHs billing inpatient Part B 101% of the allinclusive facility specific per diem rate 12X
FQHCs* All-inclusive encounter rate with other qualified services. Separate visit payment available with HCPCS. 73X
Skilled Nursing Facilities ** MPFS non-facility rate 22X, 23X
Maryland Hospitals under jurisdiction of the Health Services Cost Review Commission (HSCRC) 94% of provider submitted charges in accordance with the terms of the Maryland Waiver 12X, 13X
Home Health Agencies (can be billed only if the service is provided outside of the treatment plan) MPFS non-facility rate 34X

* Effective January 1, 2006, payment for DSMT provided in an FQHC that meets all of the requirements as above, may be made in addition to one other visit the beneficiary had during the same day, if this qualifying visit is billed on TOB 73X, with HCPCS G0108 or G0109, and revenue codes 0520, 0521, 0522, 0524, 0525, 0527, 0528, or 0900.

** The SNF consolidated billing provision allows separate part B payment for training services for beneficiaries that are in skilled Part A SNF stays, however, the SNF must submit these services on a 22 bill type. Training services provided by other provider types must be reimbursed by X the SNF.

NOTE: An ESRD facility is a reasonable site for this service, however, because it is required to provide dietician and nutritional services as part of the care covered in the composite rate, ESRD facilities are not allowed to bill for it separately and do not receive separate reimbursement. Likewise, an RHC is a reasonable site for this service, however it must be provided in an RHC with other qualifying services and paid at the all-inclusive encounter rate.

Deductible and co-insurance apply.

References:

Coding and Payment of DSMT Services (Rev. 1255, 07-02-07). (2015, July 6). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/coding-and-payment-of-dsmt-services-for-ultrasound-screening-for-abdominal-aortic-aneurysm-rev-1255-07-02-07-27031.html

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