Guidelines For Enhancing Access to Both MNT And DSMT Benefits For Medicare Part B Beneficiaries

• Intended Audiences
• Program Management, Implementation and Coordination of the Medicare DSMT and MNT benefits
• Providing Care for Medicare Part B Beneficiaries
• Quality Improvement Tips
• Coordination of the MNT and DSMT Benefits with Examples

Intended Audiences

• Program Coordinators and staff of American Diabetes Association Recognized Programs (ERPs) or Indian Health Services Recognized Programs
• Diabetes educators and other health care professionals
• Health care facility administrators

The MNT coverage from the Centers for Medicare & Medicaid Services (CMS) for qualified Part B Medicare beneficiaries with diabetes, offers an opportunity for programs to increase access to diabetes education, as well as to expand services to qualified Medicare beneficiaries. As many DSMT programs continue to seek ways to enrich their available services and establish an administratively sound program, the addition of this new Medicare benefit can help achieve those program goals. This document is designed to provide information for program coordinators so that they can appropriately enhance access and services.

For additional information on either program, access information on the Diabetes Care and Education dietetic practice group http://www.dce.org/ of the American Dietetic Association, the American Diabetes Association and the American Association of Diabetes Educators and the American Association of Diabetes Educators http://www.aadenet.org/, and the American Dietetic Association www.eatright.org/gov.

For questions about the DSMT Recognition Program, please contact the Education Recognition Program at erp@diabetes.org

Program Management, Implementation and Coordination of the Medicare DSMT and MNT Benefits

The following recommendations are provided from a management and an operational perspective to ensure the appropriate coordination and implementation of the two separate Medicare benefits. They offer suggestions for how to design your program so that all eligible Medicare beneficiaries have appropriate access to both benefits and to accurately document what is being provided and what the program is reimbursed. Three examples are included to illustrate how to best coordinate the MNT and DSMT benefits.

• All RD's, even those providing DSMT services within an accredited program (ADA-ERP or Indian Health Services), who want to provide Medicare MNT to qualifying beneficiaries with diabetes and non-dialysis kidney disease, must apply for and receive a Medicare PIN number before submitting a claim for Medicare reimbursement for medically necessary MNT services, using one of the three approved CPT codes. RD's who elect not to become a Medicare provider will not be able to bill Medicare for MNT.
  
  
• Having RD's become Medicare providers of MNT presents an opportunity to offer MNT services to appropriately qualified beneficiaries who have the required physician referral. RDs may re-assign the payment for Medicare MNT services to their employer, who then would bill and collect payment for the RD. RDs who elect not to become a Medicare provider will not be able to bill Medicare for MNT for diabetes or non-dialysis kidney disease. RDs can review information on not enrolling or opting out of the Medicare program from the American Dietetic Association's Web page www.eatright.org/gov. Individuals must be an American Dietetic Association member to access the Medicare provider information section of this website.
  
  
• Where appropriate, consider expanding your diabetes care services available to qualified Medicare beneficiaries by adding MNT provided by an RD who is participating in the Medicare program.
  
  
• Be sure to provide MNT and DSMT on separate dates of service. According to the National Coverage Guidelines from CMS, this separation is a requirement to successfully coordinate these two distinct Medicare benefits. This requirement refers to the date that the DSMT and MNT services are provided, not the date they are billed.
  
  
• Identify the other resources in your community who also provide MNT and DSMT. Learn about services available, caseload capacity and hours of operation to determine whether there is a need for additional services.
  
  
• Initiate marketing for both your DSMT and MNT services within your program(s), institution and community. If you offer both services, provide sufficient education to your referral sources about the availability, coverage criteria and coordination of both benefits. It is important to ensure that the beneficiary appropriately qualifies for both services and has the necessary referrals for both services.
  
  
• Plan marketing activities on a regular basis, according to your capacity to provide medically necessary services to qualified beneficiaries.
  
  
• Share a summary of medical and behavioral outcomes data with referral sources on regular basis. Highlight information about program requirements and your program goals.
  
  
• In collaboration with your business office or accountant, develop methods to submit claims accurately, ensure the adequacy and accuracy of your supporting documentation and to track reimbursements, co-payments, deductibles, disallowances, denials and expenses. Develop methods in your setting to track charges and receipts for both MNT and DSMT. On a regular basis, analyze reimbursement patterns and note problems to be solved.
  
  
• If feasible in your setting, track your referral sources for both MNT and DSMT and review data periodically. Target referral sources that refer for only one of these services, and plan a marketing approach to educate the referral sources about the availability and the conditions of coverage for the MNT benefit. Where medically necessary and in compliance with regulations, encourage referrals for both MNT and DSMT for those beneficiaries that appropriately qualify for both benefits and have the required physician certifications and referrals.
  
  
• Review referral data with program staff in staff meetings or at your Diabetes Education Advisory Committee meetings to create team ownership of successes & challenges and as part of your Quality Improvement process.
  
  
• Initiate a system of reminders for return appointments to ensure appropriate beneficiary follow-up care and to promote full access to the MNT and DSMT benefits.

Providing Care for Medicare Part B Beneficiaries

• Discuss that DSMT and MNT are distinct, but complementary services, and why both are necessary for quality diabetes care. Also be sure Medicare Part B beneficiaries understand they are entitled to both services if they meet the diagnostic criteria and medical necessity requirements for both benefits and have the required referrals.
  
  
• Initial DSMT provides group education for needed content areas of DSMT with peer support. Individual DSMT may be allowed in cases where there is no group class available for at least 2 months, or if the beneficiary assessment reveals group education is inappropriate due to physical handicaps, etc.
  
  
• The MNT benefit may be provided individually and in groups, and requires use of nationally recognized protocols/guides.
  
  
• Follow-up MNT requires an order from a physician's order, and follow-up DSMT requires an order from a physician or qualified non-physician practitioner.
  
  
• Review the importance of tracking behavioral goals, as related to clinical care and program evaluation with beneficiaries. Explain that managing diabetes can be difficult and most people do better with ongoing coaching. This can also help ensure that the beneficiary will follow up with you.
  
  
• Document thoroughly and accurately. In your clinical records, be sure to include copy of the MD referral, beneficiary's chief complaint (reason for visit, in beneficiary's own words), beneficiary's current diagnosis (plus relevant past diagnoses), beneficiary lab results and current medications, date of MNT visit and amount of time spent with the beneficiary, names of others present during MNT visit. Before providing services, verify that the beneficiary is eligible (i.e., has Medicare Part B coverage; physician referral) and qualified (appropriate diagnosis, lab values etc.) to receive MNT services.

Quality Improvement Tips

Develop/utilize quality review for the diabetes care services that include evaluation of:

• Delivery System design
  • Institute communication between the beneficiary, RD provider(s) and DSMT staff. Team members are aware of and engage in regular planned and informal communication around planning, coordinating and sharing results of Medicare beneficiary care.
• Clinical Information Systems
  • Develop a registry of Medicare beneficiaries with diabetes, with ability to query for diagnostic criteria for DSMT and MNT
  • Systematic monitoring
  • Performance tracking and feedback
• Decision Support Systems
  • Develop a process for insuring the incorporation of policies, guidelines, education and practice aids to assure awareness of and adherence to evidence based care. (MNT protocols)
• Self Management Support
  • The systematic provision of education and supportive interventions that increase the beneficiary's skills and confidence in managing their health problems including regular assessment of progress and problems, goal setting and problem-solving support. (DSMT)

Coordination of the MNT and DSMT Benefits

The following are only examples of how the DSMT and MNT benefits can be used and are not all inclusive of all program designs

Example #1-Scheduling for beneficiary when physician refers beneficiary for Medicare MNT for diabetes and DSMT (1^st year of services). Both benefits occurring simultaneously.

Beneficiary with newly diagnosed type 2 diabetes referred by his/her treating physician to RD for initial MNT (3 hours plus additional hours based on physician referral). In the course of the nutrition assessment, the RD determines that Medicare beneficiary would benefit from a DSMT program offered at a local hospital. RD contacts the physician to discuss medical necessity for initial DSMT and the physician determines that DSMT is medically necessary and refers beneficiary for initial DSMT. The chart below details an example of how the beneficiary would be scheduled for integrated DSMT and MNT and how these services are coded for billing.