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DSMT/MNT
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Enhancing Your Benefit
Guidelines For Enhancing Access to Both MNT
And DSMT Benefits For Medicare Part B Beneficiaries
Intended
Audiences
- Program Coordinators and staff of American
Diabetes Association Recognized Programs (ERPs) or Indian Health Services
Recognized Programs
- Diabetes educators and other health care
professionals
- Health care facility administrators
The MNT coverage from the Centers for Medicare
& Medicaid Services (CMS) for qualified Part B Medicare beneficiaries with
diabetes, offers an opportunity for programs to increase access to diabetes
education, as well as to expand services to qualified Medicare beneficiaries. As
many DSMT programs continue to seek ways to enrich their available services and
establish an administratively sound program, the addition of this new Medicare
benefit can help achieve those program goals. This document is designed to
provide information for program coordinators so that they can appropriately
enhance access and services.
For additional information on either program,
access information on the Diabetes Care and Education dietetic practice group www.dce.org
of the American Dietetic Association, the American Diabetes Association
and the American Association of Diabetes Educators www.aadenet.org,
and the American Dietetic Association www.eatright.org/gov.
For questions about the DSMT Recognition Program,
please contact the Education Recognition Program at erp@diabetes.org
Program Management,
Implementation and Coordination of the Medicare DSMT and MNT Benefits
The following recommendations are provided from a
management and an operational perspective to ensure the appropriate coordination
and implementation of the two separate Medicare benefits. They offer suggestions
for how to design your program so that all eligible Medicare beneficiaries have
appropriate access to both benefits and to accurately document what is being
provided and what the program is reimbursed. Three examples are included to
illustrate how to best coordinate the MNT and DSMT benefits.
- All RD's, even those providing DSMT services
within an accredited program (ADA-ERP or Indian Health Services), who want to
provide Medicare MNT to qualifying beneficiaries with diabetes and non-dialysis
kidney disease, must apply for and receive a Medicare PIN number before
submitting a claim for Medicare reimbursement for medically necessary MNT
services, using one of the three approved CPT codes. RD's who elect not to
become a Medicare provider will not be able to bill Medicare for MNT.
- Having RD's become Medicare providers of MNT
presents an opportunity to offer MNT services to appropriately qualified
beneficiaries who have the required physician referral. RDs may re-assign the
payment for Medicare MNT services to their employer, who then would bill and
collect payment for the RD. RDs who elect not to become a Medicare provider will
not be able to bill Medicare for MNT for diabetes or non-dialysis kidney
disease. RDs can review information on not enrolling or opting out of the
Medicare program from the American Dietetic Association's Web page www.eatright.org/gov.
Individuals must be an American Dietetic Association
member to access the Medicare provider information section of this website.
- Where appropriate, consider expanding your
diabetes care services available to qualified Medicare beneficiaries by adding
MNT provided by an RD who is participating in the Medicare program.
- Be sure to provide MNT and DSMT on separate
dates of service. According to the National Coverage Guidelines from CMS, this
separation is a requirement to successfully coordinate these two distinct
Medicare benefits. This requirement refers to the date that the DSMT and MNT
services are provided, not the date they are billed.
- Identify the other resources in your community
who also provide MNT and DSMT. Learn about services available, caseload capacity
and hours of operation to determine whether there is a need for additional
services.
- Initiate marketing for both your DSMT and MNT
services within your program(s), institution and community. If you offer both
services, provide sufficient education to your referral sources about the
availability, coverage criteria and coordination of both benefits. It is
important to ensure that the beneficiary appropriately qualifies for both
services and has the necessary referrals for both services.
- Plan marketing activities on a regular basis,
according to your capacity to provide medically necessary services to qualified
beneficiaries.
- Share a summary of medical and behavioral
outcomes data with referral sources on regular basis. Highlight information
about program requirements and your program goals.
- In collaboration with your business office or
accountant, develop methods to submit claims accurately, ensure the adequacy and
accuracy of your supporting documentation and to track reimbursements,
co-payments, deductibles, disallowances, denials and expenses. Develop methods
in your setting to track charges and receipts for both MNT and DSMT. On a
regular basis, analyze reimbursement patterns and note problems to be solved.
- If feasible in your setting, track your
referral sources for both MNT and DSMT and review data periodically. Target
referral sources that refer for only one of these services, and plan a marketing
approach to educate the referral sources about the availability and the
conditions of coverage for the MNT benefit. Where medically necessary and in
compliance with regulations, encourage referrals for both MNT and DSMT for those
beneficiaries that appropriately qualify for both benefits and have the required
physician certifications and referrals.
- Review referral data with program staff in
staff meetings or at your Diabetes Education Advisory Committee meetings to
create team ownership of successes & challenges and as part of your Quality
Improvement process.
- Initiate a system of reminders for return
appointments to ensure appropriate beneficiary follow-up care and to promote
full access to the MNT and DSMT benefits.
Providing Care for
Medicare Part B Beneficiaries
- Discuss that DSMT and MNT are distinct, but
complementary services, and why both are necessary for quality diabetes care.
Also be sure Medicare Part B beneficiaries understand they are entitled to both
services if they meet the diagnostic criteria and medical necessity requirements
for both benefits and have the required referrals.
- Initial DSMT provides group education for
needed content areas of DSMT with peer support. Individual DSMT may be allowed
in cases where there is no group class available for at least 2 months, or if
the beneficiary assessment reveals group education is inappropriate due to
physical handicaps, etc.
- The MNT benefit may be provided individually
and in groups, and requires use of nationally recognized protocols/guides.
- Follow-up MNT requires an order from a
physician's order, and follow-up DSMT requires an order from a physician or
qualified non-physician practitioner.
- Review the importance of tracking behavioral
goals, as related to clinical care and program evaluation with beneficiaries.
Explain that managing diabetes can be difficult and most people do better with
ongoing coaching. This can also help ensure that the beneficiary will follow up
with you.
- Document thoroughly and accurately. In your
clinical records, be sure to include copy of the MD referral, beneficiary's
chief complaint (reason for visit, in beneficiary's own words), beneficiary's
current diagnosis (plus relevant past diagnoses), beneficiary lab results and
current medications, date of MNT visit and amount of time spent with the
beneficiary, names of others present during MNT visit. Before providing
services, verify that the beneficiary is eligible (i.e., has Medicare Part B
coverage; physician referral) and qualified (appropriate diagnosis, lab values
etc.) to receive MNT services.
Quality
Improvement Tips
Develop/utilize quality review for the diabetes
care services that include evaluation of:
- Delivery System design
- Institute communication between the beneficiary, RD provider(s) and DSMT
staff. Team members are aware of and engage in regular planned and informal
communication around planning, coordinating and sharing results of Medicare
beneficiary care.
- Clinical Information Systems
- Develop a registry of Medicare beneficiaries with diabetes, with ability to
query for diagnostic criteria for DSMT and MNT
- Systematic monitoring
- Performance tracking and feedback
- Decision Support Systems
- Develop a process for insuring the incorporation of policies, guidelines,
education and practice aids to assure awareness of and adherence to evidence
based care. (MNT protocols)
- Self Management Support
- The systematic provision of education and supportive interventions that
increase the beneficiary's skills and confidence in managing their health
problems including regular assessment of progress and problems, goal setting and
problem-solving support. (DSMT)
Coordination of the
MNT and DSMT Benefits
The following are
only examples of how the DSMT and MNT benefits can be used and are not all
inclusive of all program designs
Example #1-Scheduling
for beneficiary when physician refers beneficiary for Medicare MNT for diabetes and
DSMT (1st year of services). Both benefits occurring simultaneously.
Beneficiary with newly diagnosed type 2 diabetes
referred by his/her treating physician to RD for initial MNT (3 hours plus
additional hours based on physician referral). In the course of the nutrition
assessment, the RD determines that Medicare beneficiary would benefit from a
DSMT program offered at a local hospital. RD contacts the physician to discuss
medical necessity for initial DSMT and the physician determines that DSMT is
medically necessary and refers beneficiary for initial DSMT. The chart below
details an example of how the beneficiary would be scheduled for integrated DSMT
and MNT and how these services are coded for billing.
|
Client Appt. |
CPT Code |
Service/
Visit
|
Brief overview of components |
Time |
|
1 |
97802 |
MNT (1) |
Individual
- Nutrition assessment, identification of
nutrition problems, and nutrition intervention by RD according to MNT
protocols. Select from assessment factors and therapeutic lifestyle
changes recommended in the MNT protocol.
- RD identifies beneficiary has not had
DSMT, documents recommendation for DSMT program while beneficiary
receives MNT; discusses recommendation with physician
- RD schedules MNT second visit for 2-4
weeks after first MNT visit
- Document outcomes
|
1.5 hours |
|
2 |
GO108 |
DSMT (1) |
Individual
- Individual assessment and insulin
training (if needed) for diabetes education class
|
1 hour |
|
3, 4, 5 |
GO109 |
DSMT (2,3,4) |
Group
- 3 diabetes classes - each class 3
hours long. Classes cover all 10 content areas (including nutrition).
DSMT program communicates beneficiary learning goals with referring RD
who will review and reinforce progress towards goals
|
9 hours |
|
6 |
97803 |
MNT (2) |
Individual
- Reassess and identify new therapeutic
lifestyle changes and goals with RD. Select from assessment and
therapeutic lifestyle changes recommended in the MNT protocol
- RD reinforces MNT individual plan and
DSMT grou
providing the nutrition content in the DSMT program, seek out
information and goals and content included in both MNT and DSMT
program. Reinforce DSMT concepts in follow-up MNT visits.)
- RD schedules MNT next visit for 2-4
weeks after first MNT visit
- Document outcomes
|
45 min |
|
7 |
97803 |
MNT (3) |
Individual
- Reassess and identify new therapeutic
lifestyle changes and goals with RD as recommended for follow-up in
the MNT protocols.
- RD integrates MNT and DSMT goals
- Evaluate outcomes to determine medical
necessity for continued MNT, obtain physician referral if indicated
- Document outcomes
|
45 min |
Total: 13 hours (10 hours DSMT, 3 hours MNT)
Example #2-DSMT program initiated first, then
physician referral to RD Medicare provider from
MNT
(1st year of education):
Scheduling for beneficiary with type 2 diabetes
for 10 years and has received no previous diabetes education. Treating provider
refers the beneficiary to DSMT program. The beneficiary meets eligibility for
DSMT because there is change of therapy - needs to start on insulin. Nurse
educator who does initial assessment indicates that the Medicare beneficiary
would benefit from MNT. Nurse communicates with physician and dietitian. The
physician determines that MNT is medically necessary and refers beneficiary for
initial MNT provided by RD.
|
Client Appt. |
CPT Code |
Service
/Visit
|
Brief overview of components |
Time |
|
1 |
GO 108 |
DSMT (1) |
Individual
- Individual assessment, check monitoring
and insulin skills for diabetes education class
- DSMT practitioner identifies that
beneficiary would benefit from MNT provided by qualifying RD;
documents recommendations in DSMT assessment/
program goals. Discusses
recommendation with physician to initiate referral for MNT
|
1 hour |
|
2 |
97802 |
MNT (1) |
Individual
- Nutrition assessment, identification of
nutrition problems, and nutrition intervention with RD according to
MNT protocols. Select from assessment factors and therapeutic
lifestyle changes recommended in the MNT protocol
- RD schedules MNT second visit for 2-4
weeks after first MNT visit (mid cycle of DSMT classes)
- Document outcomes
|
1.5 hours |
|
3, 4, 5, 6 |
GO 109 |
DSMT
(2,3,4,5) |
Group
- 4 diabetes classes - each class 2
hours long. Classes cover all 10 content areas (including nutrition).
DSMT program communicates beneficiary learning goals with RD who will
review and reinforce progress towards goals
|
8 hours |
|
7 |
97803 |
MNT (2) |
Individual
- Reassess and identify new therapeutic
lifestyle changes and goals with RD. Select from assessment and
therapeutic lifestyle changes recommended in the MNT protocol.
- RD communicates the MNT progress and
identifies nutrition education needs to DSMT program coordinator
- RD schedules next MNT visit in 2 weeks
- Document outcomes
|
45 minutes |
|
8 |
GO 109 |
DSMT (6) |
Group DSMT - assess progress towards
goals
|
1 hour |
|
9 |
97803 |
MNT (3) |
Individual
- Reassess and identify new therapeutic
lifestyle changes and goals with RD. Select from assessment and
therapeutic lifestyle changes recommended in the MNT protocol.
- Evaluate outcomes to determine medical
necessity for continued MNT, obtain physician referral if indicated
- Document outcomes
|
45 minutes |
Total: 13 hours (10 hours DSMT, 3 hours MNT)
Example 3-Follow-up MNT and DSMT benefits (year
2)
It is now one year later. A beneficiary with type
2 diabetes has completed an initial DSMT program and received initial MNT from
an RD who is a Medicare provider. Both services were provided during the same
episode of care (12 months). The beneficiary is referred by his primary care
physician to the DSMT program for insulin pen instruction and Cardiovascular
Risk Reduction instruction and to the RD for follow-up MNT.
Background information: Qualifying beneficiaries
with diabetes are eligible for 2 hours of follow-up DSMT and 2 hours of
follow-up MNT if they meet the diagnostic criteria and medical necessity
required for both benefits and if both are ordered by the provider. Both
programs can provide follow-up in a group or individual setting. Keep in mind
that according to National Coverage guidelines from the Centers for Medicare
& Medicaid Services the treating physician can refer the beneficiary for
additional hours of MNT beyond the initial 2 hours of follow-up MNT if the
treating physician determines 1) there is a change in medical condition,
diagnosis, or treatment regimen that requires a change in MNT and 2) orders
additional hours of MNT during the episode of care.
|
Client Appt. |
CPT Code |
Service/
Visit |
Brief overview of components |
Time |
|
1 |
GO 109 |
DSMT (1) |
Group
- Cardiovascular risk reduction class
|
1 hour |
|
2 |
97803 |
MNT (1)
|
Individual (see MNT protocols for details)
- Reassess and identify new therapeutic
lifestyle changes and goals with RD. Select from assessment and
therapeutic lifestyle changes recommended in the MNT protocol
- Schedule next follow-up MNT visit
- Document outcomes
|
1 hour |
|
3 |
GO 109 |
DSMT (2)
|
Group
- Referral for insulin pen instruction and
pattern management review
|
1 hour |
|
4 |
97803 |
MNT (2)
|
Individual
- Reassess and identify new therapeutic
lifestyle changes and goals with RD. Select from assessment and
therapeutic lifestyle changes recommended in the MNT protocol
- Schedule next follow-up MNT visit
- Document outcomes
|
1/2 hour
|
|
5 |
97803 |
MNT (3) |
- Reassess and identify new therapeutic
lifestyle changes and goals RD. Select from assessment and therapeutic
lifestyle changes recommended in the MNT protocol.
- Evaluate outcomes to determine medical
necessity for continued MNT, obtain physician referral if indicated
- Document outcomes
|
1/2 hour |
Total: 4 hours (2 hours DSMT, 2 hours MNT)
