Medicare Diabetes Prevention Program in Response to COVID-19 Outbreak



    Policy Impacted

    MA00.003m: Preventive Care Services



    Purpose

    The purpose of this News Article is to provide advance notice regarding coverage for Medicare diabetes prevention program in response to Coronavirus Disease 2019 (COVID-19).

    This News Article addressing Medicare diabetes prevention program is effective from March 6, 2020 through June 30, 2020 and is subject to reevaluation for the duration of the public health emergency.



    Background

    There is currently an outbreak of respiratory disease caused by a novel coronavirus, which has now been detected internationally. The virus has been named “SARS-CoV-2” and the disease it causes has been named “Coronavirus Disease 2019” (COVID-19). The SARS-CoV-2 virus has demonstrated the capability to rapidly spread, leading to significant impacts on healthcare systems and causing societal disruption. The potential public health threat posed by COVID-19 is high globally. To effectively respond to the COVID-19 outbreak, rapid detection of cases and contacts, appropriate clinical management and infection control, and implementation of community mitigation efforts are critical.

    In response to the COVID 19 outbreak, the Centers for Medicare and Medicaid Services (CMS) has waived requirements on multiple services to allow the continuation of medical treatment and minimize potential exposure. CMS made the following temporary changes to the Medicare diabetes prevention program (MDPP):
    • Increase the number of virtual make-up sessions that can be offered by MDPP suppliers.
    • Allow MDPP suppliers that have the capability, to deliver certain sessions virtually.
    • Waive the once per life time benefit and allow MDPP beneficiaries whose sessions were suspended to resume sessions or start over.



    Indications

    N/A



    Coverage Statement

    Medicare diabetes prevention program (MDPP) is covered as a preventive service for individuals enrolled in a program approved by the Centers for Disease Control and Prevention (CDC) for all sessions when all of the following criteria are met:
    • Body Mass Index (BMI) of at least 25 (23 if self-identified as Asian) on the date of the first core session
    • Any of the following blood test requirements have been met:
      • A hemoglobin A1c test with a value between 5.7% and 6.4%
      • A fasting plasma glucose of 110-125 mg/dL
      • A 2-hour plasma glucose of 140-199 mg/dL (oral glucose tolerance test)
    • No documented history of diabetes prior to the date of the first core session (with the exception of gestational diabetes)
    • No diagnosis of end-stage renal disease (ESRD)
    • Has not previously received diabetes prevention program services.

    Note: Sessions will be covered when performed through a face-to-face or virtual (e.g., not in person) encounter.


    FREQUENCY

    MDPP sessions are covered as a preventive service over a two year period. For the duration of the COVID-19 outbreak, this benefit is covered more than once during a member’s lifetime.

    Core Sessions
    Core sessions are the sessions that are provided in the first 6 months of starting the program. A minimum of 16 core sessions provided at least a week apart are covered as a preventive service.

    Core Maintenance Sessions
    Core maintenance sessions are the sessions that are provided in the following 6 months after the core sessions. A minimum of 6 monthly sessions are covered as a preventive service.

    Ongoing Maintenance Sessions
    Ongoing maintenance sessions are sessions that are provided in the following 12 months after the core maintenance sessions. Monthly ongoing maintenance sessions are covered as a preventive service when the individual has documentation of a 5% weight loss during a month 10 through month 12 face-to-face session of the core maintenance sessions.



    Dosing and Administration

    N/A



    Black Box Warnings and/or Contraindications

    N/A



    Coding

    CPT Procedure Code Number(s) N/A
    ICD-10 Diagnosis Code Number(s) and Narrative(s)R73.01 Impaired fasting glucose

    R73.02 Impaired glucose tolerance (oral)

    R73.03 Prediabetes

    R73.09 Other abnormal glucose

    Z68.23 Body mass index (BMI) 23.0-23.9, adult

    Z68.24 Body mass index (BMI) 24.0-24.9, adult

    Z68.25 Body mass index (BMI) 25.0-25.9, adult

    Z68.26 Body mass index (BMI) 26.0-26.9, adult

    Z68.27 Body mass index (BMI) 27.0-27.9, adult

    Z68.28 Body mass index (BMI) 28.0-28.9, adult

    Z68.29 Body mass index (BMI) 29.0-29.9, adult

    Z68.30 Body mass index (BMI) 30.0-30.9, adult

    Z68.31 Body mass index (BMI) 31.0-31.9, adult

    Z68.32 Body mass index (BMI) 32.0-32.9, adult

    Z68.33 Body mass index (BMI) 33.0-33.9, adult

    Z68.34 Body mass index (BMI) 34.0-34.9, adult

    Z68.35 Body mass index (BMI) 35.0-35.9, adult

    Z68.36 Body mass index (BMI) 36.0-36.9, adult

    Z68.37 Body mass index (BMI) 37.0-37.9, adult

    Z68.38 Body mass index (BMI) 38.0-38.9, adult

    Z68.39 Body mass index (BMI) 39.0-39.9, adult

    Z68.41 Body mass index (BMI) 40.0-44.9, adult

    Z68.42 Body mass index (BMI) 45.0-49.9, adult

    Z68.43 Body mass index (BMI) 50-59.9, adult

    Z68.44 Body mass index (BMI) 60.0-69.9, adult

    Z68.45 Body mass index (BMI) 70 or greater, adult

    Z68.52 Body mass index (BMI) pediatric, 5th percentile to less than 85th percentile for age

    Z68.53 Body mass index (BMI) pediatric, 85th percentile to less than 95th percentile for age

    Z68.54 Body mass index (BMI) pediatric, greater than or equal to 95th percentile for age
    HCPCS Level II Code Number(s) and Narrative(s)G9873 First Medicare Diabetes Prevention Program (MDPP) core session was attended by an MDPP beneficiary under the MDPP Expanded Model (EM). A core session is an MDPP service that: (1) is furnished by an MDPP supplier during months 1 through 6 of the MDPP services period; (2) is approximately 1 hour in length; and (3) adheres to a CDC-approved DPP curriculum for core sessions

    G9874 Four total Medicare Diabetes Prevention Program (MDPP) core sessions were attended by an MDPP beneficiary under the MDPP Expanded Model (EM). A core session is an MDPP service that: (1) is furnished by an MDPP supplier during months 1 through 6 of the MDPP services period; (2) is approximately 1 hour in length; and (3) adheres to a CDC-approved DPP curriculum for core sessions.

    G9875 Nine total Medicare Diabetes Prevention Program (MDPP) core sessions were attended by an MDPP beneficiary under the MDPP Expanded Model (EM). A core session is an MDPP service that: (1) is furnished by an MDPP supplier during months 1 through 6 of the MDPP services period; (2) is approximately 1 hour in length; and (3) adheres to a CDC-approved DPP curriculum for core sessions

    G9876 Two Medicare Diabetes Prevention Program (MDPP) core maintenance sessions (MS) were attended by an MDPP beneficiary in months (mo) 7-9 under the MDPP Expanded Model (EM). A core maintenance session is an MDPP service that: (1) is furnished by an MDPP supplier during months 7 through 12 of the MDPP services period; (2) is approximately 1 hour in length; and (3) adheres to a CDC-approved DPP curriculum for maintenance sessions. The beneficiary did not achieve at least 5% weight loss (WL) from his/her baseline weight, as measured by at least one in-person weight measurement at a core maintenance session in months 7-9.

    G9877 Two Medicare Diabetes Prevention Program (MDPP) core maintenance sessions (MS) were attended by an MDPP beneficiary in months (mo) 10-12 under the MDPP Expanded Model (EM). A core maintenance session is an MDPP service that: (1) is furnished by an MDPP supplier during months 7 through 12 of the MDPP services period; (2) is approximately 1 hour in length; and (3) adheres to a CDC-approved DPP curriculum for maintenance sessions. The beneficiary did not achieve at least 5% weight loss (WL) from his/her baseline weight, as measured by at least one in-person weight measurement at a core maintenance session in months 10-12.

    G9878 Two Medicare Diabetes Prevention Program (MDPP) core maintenance sessions (MS) were attended by an MDPP beneficiary in months (mo) 7-9 under the MDPP Expanded Model (EM). A core maintenance session is an MDPP service that: (1) is furnished by an MDPP supplier during months 7 through 12 of the MDPP services period; (2) is approximately 1 hour in length; and (3) adheres to a CDC-approved DPP curriculum for maintenance sessions. The beneficiary achieved at least 5% weight loss (WL) from his/her baseline weight, as measured by at least one in-person weight measurement at a core maintenance session in months 7-9.

    G9879 Two Medicare Diabetes Prevention Program (MDPP) core maintenance sessions (MS) were attended by an MDPP beneficiary in months (mo) 10-12 under the MDPP Expanded Model (EM). A core maintenance session is an MDPP service that: (1) is furnished by an MDPP supplier during months 7 through 12 of the MDPP services period; (2) is approximately 1 hour in length; and (3) adheres to a CDC-approved DPP curriculum for maintenance sessions. The beneficiary achieved at least 5% weight loss (WL) from his/her baseline weight, as measured by at least one in-person weight measurement at a core maintenance session in months 10-12

    G9880 The MDPP beneficiary achieved at least 5% weight loss (WL) from his/her baseline weight in months 1-12 of the MDPP services period under the MDPP Expanded Model (EM). This is a one-time payment available when a beneficiary first achieves at least 5% weight loss from baseline as measured by an in-person weight measurement at a core session or core maintenance session.

    G9881 The MDPP beneficiary achieved at least 9% weight loss (WL) from his/her baseline weight in months 1-24 under the MDPP Expanded Model (EM). This is a one-time payment available when a beneficiary first achieves at least 9% weight loss from baseline as measured by an in-person weight measurement at a core session, core maintenance session, or ongoing maintenance session.

    G9882 Two Medicare Diabetes Prevention Program (MDPP) ongoing maintenance sessions (MS) were attended by an MDPP beneficiary in months (mo) 13-15 under the MDPP Expanded Model (EM). An ongoing maintenance session is an MDPP service that: (1) is furnished by an MDPP supplier during months 13 through 24 of the MDPP services period; (2) is approximately 1 hour in length; and (3) adheres to a CDC-approved DPP curriculum for maintenance sessions. The beneficiary maintained at least 5% weight loss (WL) from his/her baseline weight, as measured by at least one in-person weight measurement at an ongoing maintenance session in months 13-15.

    G9883 Two Medicare Diabetes Prevention Program (MDPP) ongoing maintenance sessions (MS) were attended by an MDPP beneficiary in months (mo) 16-18 under the MDPP Expanded Model (EM). An ongoing maintenance session is an MDPP service that: (1) is furnished by an MDPP supplier during months 13 through 24 of the MDPP services period; (2) is approximately 1 hour in length; and (3) adheres to a CDC-approved DPP curriculum for maintenance sessions. The beneficiary maintained at least 5% weight loss (WL) from his/her baseline weight, as measured by at least one in-person weight measurement at an ongoing maintenance session in months 16-18.

    G9884 Two Medicare Diabetes Prevention Program (MDPP) ongoing maintenance sessions (MS) were attended by an MDPP beneficiary in months (mo) 19-21 under the MDPP Expanded Model (EM). An ongoing maintenance session is an MDPP service that: (1) is furnished by an MDPP supplier during months 13 through 24 of the MDPP services period; (2) is approximately 1 hour in length; and (3) adheres to a CDC-approved DPP curriculum for maintenance sessions. The beneficiary maintained at least 5% weight loss (WL) from his/her baseline weight, as measured by at least one in-person weight measurement at an ongoing maintenance session in months 19-21.

    G9885 Two Medicare Diabetes Prevention Program (MDPP) ongoing maintenance sessions (MS) were attended by an MDPP beneficiary in months (mo) 22-24 under the MDPP Expanded Model (EM). An ongoing maintenance session is an MDPP service that: (1) is furnished by an MDPP supplier during months 13 through 24 of the MDPP services period; (2) is approximately 1 hour in length; and (3) adheres to a CDC-approved DPP curriculum for maintenance sessions. The beneficiary maintained at least 5% weight loss (WL) from his/her baseline weight, as measured by at least one in-person weight measurement at an ongoing maintenance session in months 22-24.

    G9890 Bridge Payment: A one-time payment for the first Medicare Diabetes Prevention Program (MDPP) core session, core maintenance session, or ongoing maintenance session furnished by an MDPP supplier to an MDPP beneficiary during months 1-24 of the MDPP Expanded Model (EM) who has previously received MDPP services from a different MDPP supplier under the MDPP Expanded Model. A supplier may only receive one bridge payment per MDPP beneficiary.

    G9891 MDPP session reported as a line-item on a claim for a payable MDPP Expanded Model (EM) HCPCS code for a session furnished by the billing supplier under the MDPP Expanded Model and counting toward achievement of the attendance performance goal for the payable MDPP Expanded Model HCPCS code. (This code is for reporting purposes only).








    Issued on - 04/14/2020

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