General Comparisons of DSMT Benefits and MNT Medicare Benefits

When implementing one or both of Medicare covered benefits for Diabetes Self Managment Training (DSMT) and Medical Nutrition Therapy (MNT), consider the following: Referral Requirements, Benefit Coverage, Beneficiary Requirements, Place of Service Restrictions, Benefit Content, Provider Qualifications, Codes, Claims Processing Forms, Utilization Guidelines.

INDICATIONS AND LIMITATIONS OF COVERAGE AND/OR MEDICAL NECESSITY:

Referral Requirements:
DSMT

The physician or a qualified non-physician (clinical nurse specialist, physician assistant, nurse practitioner, and nurse midwife) treating the patient with diabetes must do the following:

  • Order the training.

  • Prepare a comprehensive plan of care that describes the content, number, frequency, and duration of the DSMT.

  • Determine if the diabetes training is reasonable and necessary for the treatment of the beneficiary's diabetes.

MNT

  • MNT may only be ordered by a physician.

The Benefit:
DSMT

This benefit is intended to educate beneficiaries in the successful self-management of diabetes.  The program includes instructions in self-monitoring of blood glucose; education about diet and excercise; an insulin treatment plan developed specifically for the patient who is insulin-dependent; and motivation for patients to use the skills for self-management.

The 10-hour initial training is a one-time benefit for the qualifying beneficiary. One hour of the 10-hour training may be used to assess the individual's training needs. Ten hours is the allotted timeframe to cover the 10 required content areas.

The beneficiary who receives the initial training program is eligible for two hours of follow-up training each year. Follow-up training may be divided into four sessions a year using half-hour increments.

The entity must furnish training in a group setting of two to 20 individuals. However, Medicare will cover training on an individual basis when one of the following conditions is met:

  • No group session is available within two months of the date of the training ordered.

  • The beneficiary has special needs resulting from medical conditions that would hinder participation in a group training session.

MNT

The MNT benefit, while related, is separate from the DSMT benefit.  DSMT is a comprehensive diabetes training program, of which nutrition education is only one component of group sessions.  However, medical nutrition therapy (MNT) provided by RDs specifically focuses on the nutrition assessment, nutrition problem, nutrition intervention and nutrition evaluation and monitoring for the patient.  MNT is defined in the Medicare legislation as, "nutritional diagnostic therapy and counseling services provided by a registered dietitian or nutrition professional for the purpose of managing disease."

In the CMS National Coverage Determination, the agency compares the curriculum of a DSMT program and the MNT protocols.  From this comparison, CMS determined the MNT assessment is more in-depth, the MNT benefit allows the provider to relate the individual meal plan to management of the disease process, and the MNT protocols require specific follow-up guidance with previously set nutrition goals as well as feedback.    

MNT episode of care includes three hours of basic coverage, two hours in follow-up years, and additional hours of MNT services may be covered beyond the number of hours typically covered under an episode of care when the treating physician orders additional hours based on a determination that there is a change in medical condition, diagnosis or treatment that requires a change in MNT.

  • Group session is optional and not required. Decision on group or individual would be determined case by case.

Beneficiary Requirements: Diagnostic criteria 
DSMT

A beneficiary who has one or more of the following medical conditions occurring within the 12-month period before the physician's order for the training is eligible for Medicare coverage for training from an approved entity:

  • New onset diabetes

  • Inadequate glycemic control as evidenced by glycolysated hemoglobin (A!C) of 8.5 percent or more on two consecutive determinations three or more months apart in the year before the DSMT begins

  • A change in treatment regimen from no diabetes medication to any diabetes medication, or from oral diabetes medication to insulin

  • A high risk for complications based on inadequate glycemic control (documented acute episodes of severe hypoglycemia occurring in the past year during which the beneficiary needed third party assistance for either emergency room visits or hospitalization).

  • High risk based on at least one of the following complications:
    1. Lack of feeling in the foot, or other foot complications such as foot ulcers, deformities, or amputation.
    2. Pre-proliferative or proliferative retinopathy or prior laser treatment of the eye.
    3. Kidney complications related to diabetes, when manifested by albuminuria, without other cause, or elevated creatinine.

MNT

Medicare MNT requires fasting glucose ≥126 mg/dl for type 1 and type 2 diabetes; end-stage renal disease when dialysis is not received requires diagnostic criteria of the glomulerular filtration rate (GFR) 13-50 ml/min/1.73m2; and criteria for the medical condition of a beneficiary for 36 months after a kidney transplant is the date of the kidney transplant.

Practice tip: Some beneficiaries may demonstrate unique circumstances that require special consideration. In those circumstances, a provider may submit relevant clinical information for payment consideration. Consider Advance Beneficiary Notice (ABN)

Place of Service Restrictions:
DSMT

Patients in an acute hospital, skilled nursing facility, hospice or nursing home are not eligible for DSMT. DSMT is part of their basic care and treatment in these facilities. DSMT supplied in a Federally Qualified Health Center or a Rural Health Clinic by a non-physician practitioner is bundled into the facility rate.

MNT

The Medicare MNT benefit final regulations1 indicates "Medicare will pay dietitians who enroll to obtain provider status in the Medicare program regardless of whether they provide the MNT services in an independent practice setting, hospital outpatient department or any other setting, except for services provided to patients in an inpatient stay in a hospital or skilled nursing facility."

Benefit content:
DSMT

The curriculum, instructional methods, and materials should be appropriate for the specified target population, considering type and duration of diabetes, age, cultural influences, and individual learning abilities. These programs must meet the National Diabetes Advisory Board Standards (NDAB).

MNT

Requires use of nationally recognized protocols, such as those developed by the American Dietetic Association.

Provider Qualifications:
DSMT

For DSMT the entity that is the accredited DSMT program submits the claims, not the individuals who participate on the inter-disciplinary team to provide the DSMT curriculum. It is the program that has provider status, not the individual professionals. The approved entities that supply the DSMT must meet the following conditions:

  • The provider must supply other services for which direct Medicare payment may be made.

  • The provider must supply Medicare with any documentation that is requested.

  • The provider must show proof that it has been accredited by a CMS approved accreditation organization.

  • A non-physician professional program staff must obtain 12 hours of continuing educational units every two years.

  • Payment for furnishing the DSMT is made after CMS approves the provider to furnish the services. Each provider must submit a certificate of program accreditation to the carrier, prior to billing the first claim.

  • All appropriate multidisciplinary team members must be present during the portion of the training for which they are responsible and must directly furnish the training within their scope of practice

MNT

For MNT the registered dietitian or nutrition professional must be enrolled as the Medicare provider and bill the carrier directly for MNT services, or reassign to his/her employer.

Practitioners can enroll and at any time become a Medicare provider status by completing the necessary enrollment applications forms available form the local state Medicare carriers. If the RD is employed at a clinic or facility that will submit the claims forms and collect payment on behalf of the RD, the RD will need to complete a reassignment form along with the other enrollment forms.

RDs must submit their completed Medicare Provider enrollment form, specifying the date the RD will start providing MNT services from their practice location (list date service will begin in Section 4B 1 on CMS855I form). Do not provide Medicare MNT services before the date indicated on the provider enrollment form. If you have not received your provider identification number (PIN), you may provide the MNT service to individuals with diabetes and kidney disease, according to CMS' definition of these diseases, and whom a treating physician refers. RDs must hold the claims until you receive your PIN.

MNT does not require additional application and granting of recognition, only that RDs and qualified nutrition professionals use nationally recognized protocols.

Codes
1. REVENUE CODES: Not applicable for either benefit

2. CPT/HCPCS CODES:

DSMT

  • Requires use of G codes GO108 and GO109; 30 minute increments for both codes.

  • Report one unit (1 QB) of DSMT for each 30 minutes of training completed

MNT

  • MNT requires use of the MNT CPT codes 97802, 97803, or 97804;

  • 15 minute increments accepted for 97802 and 97803, 30 minute increments for 97804.

3. ICD-9 CODES THAT SUPPORT MEDICAL NECESSITY
For each benefit, DSMT and MNT for beneficiaries with diabetes:

  • The ICD-9-CM code used must be coded to the highest level of specificity, and it must be submitted with the claim. Truncated codes are not acceptable.

  • 250.00-250.93 Diabetes mellitus

Claims Processing Form:
DSMT

Claims may be billed on either the UB92 or HCFA1500 form, depending on the type of entity that is the accredited DSMT program

MNT

Claims must be billed using the HCFA1500 form.  Recently accepted billing form UB92; refer to Official Government Program Memorandums for updates to information listed here.

Utilization Guidelines:
DSMT

  • The 10-hour initial training is a one-time patient benefit.

  • One hour of the 10-hour training may be used for assessing the individual's training needs.

  • The beneficiary who receives the initial training program is eligible for follow-up training session of no more than two hours each year.

  • For the first 12-month period following the first date of service, Medicare will deny payment for more than 20 QB.

  • In each subsequent 12-month period, Medicare will deny payment for more than four QB.

  • Payment is made for training sessions actually attended by the beneficiary—not for a "package" of training sessions.

MNT

  • MNT and DSMT may not be provided on the same date

  • Additional hours of MNT services may be covered beyond the number of hours typically covered under an episode of care when the treating physician determines there is a change of diagnosis or medical condition within such episode of care that makes a change in diet necessary. Appropriate medical review for this provision should only be done on a post payment basis. Outliers may be judged against nationally accepted dietary or nutritional protocols in accordance with 42 CFR410.132(a).

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