Duke Health Referring Physicians

Practice Management

Medicare Creates New Billing Code for Diabetes Classes

Diabetes prevention program went into effect earlier this year

Finger prick for diabetes

Studies show that even moderate weight loss can drastically reduce the risk of prediabetes transitioning into diabetes. With that in mind, Medicare created a new billing code this year that pays health care providers for referring prediabetic beneficiaries to coaching classes aimed at encouraging lifestyle changes.

The Medicare Diabetes Prevention Program (MDPP) that went into effect on April 1 offers classroom sessions over 1 or 2 years. Payment is based on class attendance and achieving a weight loss goal of 5%. Reimbursement can be as high as $670 per beneficiary over 2 years, without requiring too much effort from providers.

“MDPP services are furnished by lifestyle coaches on behalf of MDPP suppliers,” says April M. Washington, a Centers for Medicare & Medicaid Services (CMS) public affairs officer based in Atlanta. “A coach could be an employee, contractor, or volunteer.” Coaches do not need special clinical certification or training; however, they must possess a National Provider Identifier number and be free of certain felony convictions. Suppliers can be traditional health care providers like physician practices or community-based organizations, such as YMCAs or faith-based organizations, she adds.

Classes can occur in a practice setting or at offsite locations, such as a local church. In the first 6 months of the program, suppliers must offer 16 group training sessions, at least once a week, and use a curriculum approved by the Centers for Disease Control and Prevention.

In months 6 through 12, suppliers must offer classes at least monthly. After that, eligible patients can continue to attend monthly classes for another year. Even if patients develop diabetes while enrolled in the classes, they are still eligible for the program. However, patients who are disqualified for lack of attendance or weight loss can never re-enroll. Thus, motivated patients are a must for a successful program.

Eligibility requires a body mass index of at least 25 kg/m2, or 23 kg/m2 if the patient self-identifies as Asian. Patients must also have one of the following: glycated hemoglobin between 5.7% and 6.4%, fasting plasma glucose of 110 to 125 mg/dL, or 2-hour plasma glucose of 140 to 199 mg/dL.

Although a physician referral is not required, a CMS statement notes that clinicians play a vital role: “This is particularly important because only 14% of adults aged 65 and older with prediabetes are aware of their condition.”