Treating Diabetic Patients in Your Office?

June 30th, 2017 - Shannon DeConda
Categories:   Practice Management   HCPCS Coding  
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CMS will be rolling out an Expanded Diabetes Prevention Plan January 1, 2018 as well as new Durable Medical Equipment (DME) supply codes for Continuous Glucose Monitors (CGM) July 1, 2017. These services will offer your practice the opportunity to better assist your diabetic patient's needs.

Remember that prior to providing DME supplies to a patient, you must be credentialed by Medicare as a DME supplier. For more information, visit the CMS website using this link:

Continuous Glucose Monitoring (CGM) Devices Effective July 1, 2017

In January of this year, CMS Ruling (CMS-1682-R) advised that Continuous Glucose Monitoring (CGM) will be considered DME. CMS offered the following guidance on what considerations a CGM must offer in order to meet this description.

The CGM must:

  • Be approved by the FDA for suitable use in lieu of blood glucose monitoring

  • NOT be useful to individuals not having glucose control issues

  • Be approved for home use

  • Meet the CMS definitions of durable component, meaning it can withstand repeated use for at least three years, and will display the trending for continuous glucose measurements.

Proper reporting of DME supplies typically requires the use of HCPCS codes for reimbursement through the DMERC System. To facilitate accurate reporting of these services, two new HCPCS codes have been created to report CGM:

  • K0553: Supply allowance for therapeutic continuous glucose monitor (CGM), includes all supplies and accessories, 1 unit of service = 1 month's supply

  • K0554: Receiver (Monitor), dedicated, for use with therapeutic continuous glucose monitor system

To-Do List for CGM Implementation

If you are interested in providing CGM services to your Medicare Beneficiaries, you may use the following to add to your to-do list:

1. Verify you have an active DMERC number. The key here is an active number. If you failed to provide specific updated information or re- validation, your number may have been inactivated. Additionally, CMS will typically inactivate numbers that have not been used within 6 months.

2. If you do not have a DMERC number, you will need to obtain one. Your DMERC MAC carrier may NOT be the same as your Part B MAC, so be sure you identify your DMERC Carrier using the following link: Administrative-Contractors/Downloads/DME-MAC-Jurisdiction- Map-Jan-2016.pdf

3. Investigate your options for CGM devices that meet the description set forth by CMS and work to obtain best pricing. Consider consulting with Craig King with the PowerBuying division of DoctorsManagement (our parent organization) for pricing options. You can contact Craig via email at

4. Begin staff training. You will need to have a team member trained on the CGM device, troubleshooting and application. The manufacturer or distributor representative from whom you've purchased your CGM may be able to offer this training. Don't forget to train your billing staff on the appropriate code use along with ICD-10 coding application process.

5. Be ready to implement and bill on July 1, 2017. For more information on CGM, visit: Network-MLN/MLNMattersArticles/downloads/MM10013.pdf

Medicare Diabetes Prevention Program (MDPP) Expanded Model Proposed Effective Date January 1, 2018 (Pending Final Rule)

Medicare is rolling out the Medicare Diabetes Prevention Program (MDPP) Expanded Model beginning January 1, 2018. This program will target Medicare beneficiaries with pre-diabetes in hopes of behavioral modifications to prevent Type 2 Diabetes.

Description of this proposed benefit includes:

  • 12 months of intervention, consisting of:

    • Months 1-6: At least 16 weekly "core" hour-long sessions

    • Additionally, at least 6 monthly core maintenance sessions over months 6-12, regardless of weight loss

  • If the Beneficiary achieved the minimum weight loss (5%) in the preceding 3 months, then they will also have access to 3 month intervals of ongoing maintenance sessions upon completion of this 12 months.

  • This program has no cost-sharing requirement

Eligible Beneficiaries will include those individuals who meet all of the following criteria:

  • Enrolled in Medicare Part B

  • As of the date of their first "core" session have a BMI of at least 25 (23 BMI for those of Asian descent)

  • Within 12 months prior to attending first core session, meet one of the following:

    • A1c value between 5.7-6.4 percent

    • Fasting plasma glucose of 110-125 mg/dL

    • 2 hour plasma glucose of 140-199 mg/dL

  • No previous diagnose of type 1 or type 2 diabetes with the exception of gestational diabetes

  • Does not have end-stage renal disease (ESRD)

As the final ruling is still pending, CMS has begun to outline some information regarding supplier eligibility, but additional rulemaking is required. If your organization is interested in this program, keep a watchful eye for more information that will include the requirement of the organization to have full recognition of the CDC Diabetes Prevention Recognition Program (DPRP). Organizations will provide this service through "coaches" who must have a valid NPI. The organization will be required to pass application screening at a high categorical risk level (per 42 CFR 424.518(c)) regardless of current Medicare enrollment. Final rulings will also provide information on payment structure.

To-Do List for MDPP Implementation

If you are interested in providing MDPP services to your Medicare Beneficiaries, you may use the following to add to your to-do list:

  1. Most importantly, watch for the final rule to be released to know all information on billing, supplier eligibility, and benefits/coverage.

  2. Once the final ruling is released with reimbursement details, create an internal feasibility analysis to ensure implementation of this program will be financially viable.

  3. Begin researching the CDC Diabetes Prevention Recognition Program. Here is a link to assist:

  4. Identify staff who may meet the CDC definitions of a "coach" as outlined in their standards (at the link above) on page 25 which is Appendix C.

  5. Begin identifying potential eligible beneficiaries for review of potential implementation starting January 1, 2018.

For more information on MDPP, you may visit: sheets/2016-fact-sheets-items/2016-11-02-2.html


Questions, comments?

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