Provider Notice Issued 08/20/2021

Date:    August 20, 2021

To:       All Medical Assistance Program Providers

Re:      Coverage for Diabetes Prevention and Management Programs Effective August 1, 2021

 ________________________________________________________________________________________________________ 

This notice announces new coverage for diabetes prevention and management programs effective with dates of service beginning August 1, 2021. These programs will be available to customers covered under the Medicaid fee-for-service program or a managed care plan.

HFS must await federal approval and billing system updates to proceed with coverage under the fee-for-service program. However, providers may now begin the enrollment process and the Department will update providers via provider notice at the time fee-for-service claims may be submitted. Managed care plans may begin coverage as soon as their billing systems are ready.

The Department will provide coverage and reimbursement related to two nationally recognized programs described below:

Diabetes Prevention Program (DPP)
The National Diabetes Prevention Program (DPP) is a yearlong, evidence-based lifestyle change intervention developed by the Centers for Disease Control and Prevention (CDC) to reduce the risk of adults with prediabetes progressing to Type 2 diabetes. The program achieves that goal primarily through weight loss that results from the CDC's Diabetes Prevention Lifestyle Change curriculum, which focuses on healthy eating, increasing physical activity, and managing stress. CDC-recognized DPP organizations may enroll as an Illinois Medicaid provider to administer the program to deliver a set of medically necessary services to prevent or delay the onset of Type 2 diabetes for beneficiaries with indications of prediabetes. DPP services are provided in-person or via telehealth/virtually during sessions that occur at regular, periodic intervals over the course of one year.

Diabetes Self-Management Education and Support (DSMES)
Diabetes Self-Management Education and Support (DSMES) services are provided as preventive services and must be recommended by a physician or other licensed practitioner of the healing arts within his or her scope of practice under state law to prevent diabetes or the progression of diabetes, prolong life, and/or promote the physical and mental health of the beneficiary.

Services may be provided in the home, clinic, hospital outpatient facility, via telehealth, or any other setting as authorized and include: counseling related to long-term dietary change, increased physical activity, and behavior change strategies for weight control; counseling and skill building to facilitate the knowledge, skill and ability necessary for diabetes self-care; and nutritional counseling services.

Eligible customers may receive up to 18 hours of DSMES services during each 12-month period beginning with the initial training date, including:

• Up to three hours of individual DSMES, and

• Up to fifteen hours of group DSMES

 
Both types of diabetes prevention and management services will be billable via the X12 837P transaction or the MEDI Internet electronic claim system. Claims requiring an attachment may be submitted on the HFS 2360 paper claim form. HFS 2360 paper claim form instructions are found in the Handbook Supplement.

Provider enrollment, customer eligibility criteria, reimbursement methodology, and claim coding specifications are outlined below for each program. Questions regarding this notice may be directed to the Bureau of Professional and Ancillary Services at 877-782-5565.

 
Kelly Cunningham, Administrator
Division of Medical Programs

                                                                                         Diabetes Prevention Program

• DPP Provider Enrollment via the IMPACT System
  
• Type of Enrollment – Facility, Agencies, Organizations (FAO)
• Provider Type – Diabetes Prevention Provider Organization (Legacy PT 102)
  
• Specialty - Diabetes Prevention Provider Organization
• Sub-Specialty – No Subspecialty
• Requirements – CDC certification indicating pending, preliminary, or full recognition status
• Earliest Start Date – August 1, 2021
• A Federally Qualified Health Center (FQHC), Rural Health Clinic (RHC), or Encounter Rate Clinic (ERC), even if already enrolled in IMPACT, must create a separate enrollment and obtain a separate NPI to bill for diabetes prevention services. These services will be reimbursed through the fee-for-service methodology and not the encounter rate.
  
    

• Eligibility Criteria for DPP Services

• Adults with Medicaid coverage between the ages of 18 and 64
• Be overweight or obese (Body Mass Index (BMI) of > 25 kg/m2 (> 23 kg/m2 if Asian) and
• Have elevated blood glucose level or history of gestational diabetes mellitus (GDM), meaning the enrollee has:
• Fasting glucose of 100 to 125 mg;
• Plasma glucose measured 2 hours after a 75 gm glucose load of 140 to 198 mg/dl;
• A1C level of 5.7 to 6.4; or
• Clinically diagnosed GDM during a previous pregnancy
• The customer is not required to be referred for these services.
• For customers who also have Medicare eligibility, providers must bill Medicare as the primary payer before billing Medicaid.

The reimbursement methodology available for DPP services is session and performance-based reimbursement for either in-person or virtual DPP providers.

• Taxonomy Code for Health Educator:  174H00000X

• Place of Service Codes Include:  02, 03, 04, 11, 12, 13, 14, 99

• DPP ICD-10 Diagnosis Codes
  
  The following ICD-10 diagnosis codes may be used for claim submission and reimbursement.
   

Elevated Blood Glucose Level and Gestational Diabetes ICD-10 Codes

BMI ICD-10 Codes for BMI 12.0 and Greater

DPP Provider Assignment of ICD-10 Codes and Z Codes

For each initial claim, DPP Providers must indicate two ICD-10 codes: 1) for elevated blood glucose (R73.01, R73.02, R73.03), or history of Gestational Diabetes (Z86.32), and 2) for BMI.  DPP providers may indicate R codes for elevated blood glucose if one of three scenarios are met:

1. The enrollee presents a formal provider referral with R code indicated; or
2. DPP provider receives blood test results from the enrollee's MCO or health care provider, with proper consent and authorization by the enrollee; or
3. The enrollee presents blood test results which the DPP provider may use to identify appropriate R code according to the following prediabetes definitions.

Prediabetes Definitions

Prediabetes (R73.03) is defined as any of the following 3 criteria:

• Impaired glucose tolerance (IGT) – Two-hour plasma glucose value during a 75 g OGTT between 140 and 199 mg/dL (7.8 to 11.0 mmol/L) = alone, this is the criterion for R73.02.
• Impaired fasting glucose (IFG) – Fasting plasma glucose 100 to 125 mg/dL (5.6 to 6.9 mmol/L) = alone, is the criterion for R73.01
• Hemoglobin A1C – A1C 5.7 to 6.4 percent

 
DPP providers may indicate Z code for history of Gestational Diabetes if one of three scenarios is met:

1. The enrollee presents a formal provider referral with Z code indicated; or
2. DPP Provider receives blood test results or provider note from the enrollee's MCO or health care provider, with proper consent and authorization by the enrollee; or
3. The enrollee presents blood test results or provider note indicating history of GDM or normal postpartum A1C or glucose level and a GDM diagnosis during a previous pregnancy, which the DPP provider may use to indicate the Z code.

 
For each subsequent claim, DPP providers must indicate only the appropriate code initially used to indicate diagnosis of elevated blood glucose (R codes) or history of gestational diabetes (Z86.32); they do not need to include BMI codes on any subsequent claim.

DPP providers should follow MCO guidance on how to direct members to provide the necessary blood test documentation, confirmation or formal provider referral (i.e. fax, secure email, digital photo, etc.).

Referral Sources and Assignment of ICD-10 Codes by a DPP Provider

The table below describes how DPP providers should make ICD-10 assignment according to referral source and documentation presented.
 
DPP Provider Assignment of ICD-10 Codes for Elevated Blood Glucose Level and Gestational Diabetes Based on Referral Source and Documentation Provided

• DSMES Provider Enrollment via the IMPACT System
  

• Type of Enrollment – Facility, Agencies, Organizations (FAO) 
• Provider Type – Diabetes Self-Management Education and Support Organization (Legacy PT 103)
• Specialty – Diabetes Self-Management Education and Support Organization
• Sub-Specialty –   No Subspecialty
• Requirements – Accreditation from the Association of Diabetes Care & Education Specialists (ADCES) or recognition from the American Diabetes Association (ADA)
• Earliest Start Date – August 1, 2021
• A Federally Qualified Health Center (FQHC), Rural Health Clinic (RHC), or Encounter Rate Clinic (ERC), even if already enrolled in IMPACT, must create a separate enrollment and obtain a separate NPI to bill for diabetes prevention services. These services will be reimbursed through the fee-for-service methodology and not the encounter rate.

• Eligibility Criteria for DSMES

• Adults between the ages of 18 and 64 with documentation of a diagnosis of type 1, type 2, or gestational diabetes
• Diagnosis must be made using the following criteria:

• Fasting glucose > 126 mg/dL on two separate occasions
• 2-hour post-glucose challenge > 200 mg/dL on two separate occasions
• Random glucose test > 200 mg/dL with symptoms of uncontrolled diabetes

• DSMES participants must receive a written referral from the treating qualified provider (physician, physician assistant (PA), or advanced practice nurse (APN)).
• For customers who also have Medicare eligibility, providers must bill Medicare as the primary payer before billing Medicaid.

• DSMES Reimbursement Methodology
  
  Individual and Group Reimbursement Methodology for In-Person and Telehealth DSMES
  
   

• Taxonomy Code for Health Educator:  174H00000X
  
   
• Place of Service Codes Include:  02, 03, 04, 11, 12, 13, 14, 99
  
   

• DSMES ICD-10 Diagnosis Codes

The following ICD-10 diagnosis codes may be used for billing on the initial claim for reimbursement:

Elevated Blood Glucose Level and Gestational Diabetes ICD-10 Codes