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Update to the Preventive Coverage of Medicare Diabetes Prevention Program


Purpose

Retroactively effective to January 1, 2024, in alignment with the CMS expanded model of the Medicare Diabetes Prevention Program (MDPP), this communication is intended to provide updates to the MA00.003z Preventive Care Services policy for MDPP recommendation.  ​

Coverage Statement

Based on guidance from CMS, Medicare diabetes prevention program preventive coverage was updated to 22 sessions over a one-year period. In accordance with CMS, the following HCPCS codes were removed from this recommendation: G9873, G9874, G9875, G9876, G9877, G9878, G9879, G9882, G9883, G9884, G9885, G9891.

COVERAGE

The 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)
    • Member has not previously received diabetes prevention program services

NOTE: Sessions will be covered when performed face-to-face or virtually, e.g., the encounter is not in person.

FREQUENCY

A maximum of 22 MDPP sessions are covered as a preventive service over a one-year period. In accordance with CMS, this benefit is covered once during a member's lifetime. CMS recommends 16 weekly sessions during months 1 through 6, and 6 monthly sessions during months 7 through 12. 


Coding

 

CPT Procedure Code Number(s) and Narrative(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) 50.0-59.9, 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)
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.

G9886 Behavioral counseling for diabetes prevention, in-person, group, 60 minutes

G9887 Behavioral counseling for diabetes prevention, distance learning, 60 minutes

G9888 Maintenance 5% wl from baseline weight in months 7-12

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 rec eive one bridge payment per MDPP beneficiary.
Modifier(s) and Narrative(s)VM Medicare diabetes prevention program (MDPP) virtual make-up session

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05/28/2024