Tuesday, October 8, 2019

Modifier UB, UC, UA - Billing Guidelines

Modifier  Description
UB Medically necessary delivery prior to 39 weeks of gestation
UC Delivery at 39 weeks of gestation or later
UA Nonmedically necessary delivery prior to 39 weeks of gestation

EED Policy Components

•  GAMMIS is being configured to link practitioners’ induction and delivery claims to the hospital’s induction and delivery claims

•  Induction and delivery claims that are submitted with medical conditions that do not warrant an exception for an induction or delivery prior to 39 weeks gestation will deny payment

•  For non-medically necessary deliveries:–  The practitioner’s claim will fully deny–  The hospital’s claim will deny for the induction and/or delivery portion

•  Practitioners and hospitals may submit an appeal for the denial (DMA 520-A form) to the DCH Medicaid peer review organization, Georgia Medical Care Foundation

•  Compliance will be monitored by DCH and the Centers for Medicare and Medicaid Services through Georgia’s reporting of the Early Elective Deliveries measure 14 found in the Initial Core Set of Health Quality Measures for Medicaid Eligible Adults

•  These specifications contain the same exclusions as the JCAHO list of exclusions•  CY 12 data will serve as the baseline for this CMS measure

Purpose of EED Policy

•  Guide providers and hospitals to sound practice recommendations made by ACOG and others
•  Reduce morbidity in neonates from birth trauma and fetal immaturity
•  Reduce non-medically necessary deliveries less than 39 weeks gestation
•  Encourage greater collaborations between hospitals and their physicians in developing quality improvement initiatives aimed at improving birth outcomes

Modifier/condition codes needed for maternity services/obstetric delivery - Unicare insurance billing

This provider bulletin is an update to information in the provider manual. For access to the latest manual, go to www.UniCare.com.West Virginia is ranked 44thby America’s Health Rankings for infant mortality; nearly eight (7.4) of every 1,000 children die before their first birthday. Infant mortality is a multi factorial health problem, and improving West Virginia’s infant mortality rate will require a multifaceted approach. One of the approaches of UniCare Health Plan of West Virginia, Inc. (UniCare)is to reduce early elective deliveries (EEDs) prior to 39 weeks of gestation. The initiative of reducing EEDs has received national attention from many organizations, including the Centers for Medicare & Medicaid Services (CMS), the March of Dimes, the American Congress of Obstetricians and Gynecologists (ACOG), and The Joint Commission.

Additionally, many West Virginia hospitals and their medical staffs have responded to this initiative by adopting policies that ensure early inductions and cesarean deliveries are medically necessary. UniCare is aligning its obstetric services policy with the goal of improving neonatal and maternal health outcomes. Deliveries that occur prior to 39 weeks, either due to spontaneous labor or as the result of a medically-indicated induction or cesarean section, will continue to remain covered; however,for claims to pay, a modifier or condition code is needed. Deliveries prior to 39 weeks, unless documented as a medical necessity or spontaneous labor, are not a covered benefit.

* Effective for dates of service on or after October 1, 2016,UniCare will require the above modifiers to be used when submitting a claim,or the claim will deny.

Effective for dates of admission on or after October 1, 2016, the following condition codes will be required on the CMS1450 (UB-04)claim form when billing for obstetric delivery services. Condition codes are to be placed in fields 18-24 of theCMS1450 (UB-04)claim form.

Condition code  Description

81 Cesarean sections or inductions performed at less than 39 weeks’ gestation for medical necessity

82 Cesarean sections or inductions performed at less than 39 weeks’ gestation electively

83 Cesarean sections or inductions performed at 39 weeks’ gestation or greater

 Coding for Maternity Care - Medicaid Guidelines

Gestational Age

Providers are required to report the gestational age of the fetus by using the appropriate ICD-10 diagnosis codes Z3A.00 through Z3A.49 on all delivery claims.

Modifier UC

Providers are required to append modifier UC on claims of deliveries 39 weeks or less that are medically necessary or on deliveries 39 weeks or more, whether spontaneous or elective.  If the modifier “UC” is not appended to the claim, it is understood that the claim was for an early elective delivery less than 39 weeks and 0 days and will be denied.  Providers are responsible for ensuring that the codes (and modifiers when applicable) submitted for reimbursement accurately
reflect the diagnosis and procedure(s) reported.

Modifier 22

All obstetrical and delivery procedure codes submitted with modifier 22 require submission of documentation (e.g., operative report) for review prior to payment.  Services for enhanced payment with the 22 modifier include multiple gestations or complications during the delivery which place the mother or fetus at risk of adverse outcome.

Wednesday, September 4, 2019

CPT 99500, 99502, 99504, 99511, 99601, G0068, G0070 - Home health codes

CPT Code Description

99500 Home visit for prenatal monitoring and assessment to include fetal heart rate, non-stress test, uterine monitoring, and gestational diabetes monitoring99501Home visit for postnatal assessment and follow-up care

99502 Home visit for newborn care and assessment

99503 Home visit for respiratory therapy care (e.g., bronchodilator, oxygen therapy, respiratory assessment, apnea evaluation)

99504 Home visit for mechanical ventilation care

99505 Home visit for stoma care and maintenance including colostomy and cystostomy99506Home visit for intramuscular injections

99507 Home visit for care and maintenance of catheter(s) (e.g., urinary, drainage, and enteral)

99511 Home visit for fecal impaction management and enema administration99512Home visit for hemodialysis

99601 Home infusion/specialty drug administration, per visit (up to 2 hours);

99602 Home infusion/specialty drug administration, per visit (up to 2 hours);each additional hour (List separately in addition to code for primary procedure)

G0068 Professional services for the administration of anti infective, pain management, chelation, pulmonary hypertension, and/or inotropic infusion drug(s) for each infusion drug administration calendar day in the individual's home, each 15 minutes

G0069 Professional services for the administration of subcutaneous immunotherapy for each infusion drug administration calendar day in the individual's home, each 15 minutes

G0070 Professional services for the administration of chemotherapy for each infusion drug administration calendar day in the individual's home, each 15 minutes

What Is Home Health Care?

Home health care includes skilled nursing care, as well as other skilled care services, like physical and occupational therapy, speech-language therapy, and medical social services. These services are given by a variety of skilled health care professionals at home.

 The home health staff provides and helps coordinate the care and/ortherapy your doctor orders. Along with the doctor, home health staff create a plan of care, which is a written plan for your care. It tells what services you will get to reach and keep your best physical,mental, and social well-being. The home health staff keeps your doctor up-to-date on how you are doing and updates your plan of care as needed, as authorized by your doctor. More information a bout plans of care can be found on pages 19 and 20.

The need for home health care has grown for many reasons. Medical science and technology have improved. Many treatments that could once be done only in a hospital can now be done at home. Also,home health care is usually less expensive and can often be just as effective as care in a hospital or skilled nursing facility. And just a important, most patients and their families prefer to stay at home rather than be in a hospital or a nursing home.While you get home health care, home health staff teach you (and those who help you) to continue any care you may need, including medication, wound care, therapy, and managing stress.

Since most home health care is intermittent and part-time, patients (and their informal caregivers) should learn how to identify and care for possible problems, like confusion or shortness of breath.The goal of short-term home health care is to provide treatment for an illness or injury. It helps you get better, regain your independence,and become as self-sufficient as possible. The goal of long-term home health care (for chronically ill or disabled people) is to maintain your highest level of ability or health, and help you learn to live with your illness or disability.1 -

How long can I get home health services?

Medicare covers your home health services for as long as you are eligible and your doctor says you need these services. However, the skilled nursing care and home health aide services are only covered on a part-time or “intermittent” basis. This means there are limits on the number of hours per day and days per week that you can get skilled nursing or home health aide services. Therapy services do not have to be part-time or intermittent.

To decide whether or not you are eligible for home health care,Medicare defines “intermittent” as skilled nursing care that is needed or given on fewer than seven days each week or less than eight hours each day over a period of 21 days (or less) with some exceptions in special circumstances.

What does the Original Medicare Plan pay for and what can I be billed for?

The Original Medicare Plan pays the full approved amount (cost) of all covered home health visits. The home health agency sends bills to Medicare. Before your care begins, the home health agency must tell you how much of your bill Medicare will pay. The agency must also tell you if any items or services they give you are not covered by Medicare, and how much you will have to pay for them. This must be explained both by talking with you and in writing.

You may be charged for

• medical services and supplies that Medicare doesn’t pay for, such as prescription drugs, and

• 20 percent of the approved amount for Medicare-covered medical equipment such as wheelchairs, walkers, and oxygen equipment. If the home health agency doesn’t supply medical equipment directly,the home health agency staff will arrange for a home equipment supplier to bring the items you need to your home.

Coverage Limitations and Exclusions

Covered pharmaceuticals, drugs, and DME provided in connection with home health services may be subject to separate benefit categories. Reference the Durable Medical Equipment and the Pharmaceutical Products benefit sections of the member specific benefit plan document.Home health care benefits do not include:

* Custodial Care
* Domiciliary care
* Private Duty Nursing[refer to the Coverage Determination Guideline titled Private Duty Nursing (PDN) Services]
*Respite care
* Rest cures and therefore these services are not covered (check the member specific benefit plan document)
* Homemaker services such as home meal delivery services (e.g., Meals-on-Wheels) or transportation services (e.g., Dial-a-Ride)
*Independent nurse hired directly by the family/member
* Personal care attendants (these are not home health aides)
*Home health services beyond benefit limits(e.g., number of visits)We will determine if benefits are available by reviewing both the skilled nature of the service and the need for Physician-directed medical management. A service will not be determined to be "skilled" simply because there is not an available caregiver.

Home Health Services Medicaid Guideline

Home Health Services are defined as intermittent nursing care provided by certified nursing professionals (registered nurses, licensed practical nurses, skilled nurse aides) in the client’s home when the client’s place of residence is the most appropriate and cost-effective setting consistent with the client’s medical  need. Home health care is to be rendered by a Medicare-certified Home Health Agency.

Covered Services for Home Health Services

Covered procedure codes are: T1001, S9123, T1999, S1030, T1021, T1003, T1031, S9124, T1020, S9122,T1022, S9131, S9128, G0154, S9485, S9480, T1002, G0081.

Non Covered Services for Home Health Services

a.      Nursing or aide services requested for convenience of family, i.e., bathing, feeding, exercising, homemaking services, transfer services, giving medication, or acting as a companion or sitter, which do not require training, medical judgment technical skills of a  nurse whether or not another person is available to perform such services, are not covered.

This exclusion applies regardless of whether services were recommended by a provider.

Non-covered services are:
(1)  Private duty nursing.
(2)  Custodial care.
(3)  Respite care.
(4)  Transportation, travel, escort services or food services.


What criteria must be met to qualify for home health services?

Medicare covers home health services when all of these criteria are met:

● The beneficiary to whom services are furnished is eligible and enrolled in Part A and/or Part B of the Medicare Program
● The beneficiary is eligible for coverage of home health services
● The HHA furnishing the services has a valid agreement in effect to participate in the Medicare Program
● The services for which payment is claimed are covered under the Medicare home health benefit
● Medicare is the appropriate payer and
● The services are not otherwise excluded from payment

What criteria must a patient meet to be eligible for home health services?

For a patient to be eligible for Medicare home health services, he or she must meet these criteria:

1.Be confined to the home (that is, home bound)
2.Need skilled services
3.Be under the care of a physician
4.Receive services under a home health plan of care (POC) established and periodically reviewed by a physician and
5.Had a face-to-face encounter related to the primary reason the patient requires home health services with a physician or an allowed NPP no more than 90 days prior to the home health start-of-care date or within 30 days of the start of the home health care

Thursday, July 25, 2019

CPT 21100, 21110, 21120,21121 - 21127 - Orthognathic surgery codes

CPT code and Description

21100 Application of halo type appliance for maxillofacial fixation, includes removal (separate procedure)

21110 Application of interdental fixation device for conditions other than fracture or dislocation, includes removal

21120 Genioplasty; augmentation (autograft, allograft, prosthetic material)

21121 Genioplasty; sliding osteotomy, single piece

21122 Genioplasty; sliding osteotomies, two or more osteotomies (e.g., wedge excision or bone wedge reversal for asymmetrical chin)

21123 Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts)

21125 Augmentation, mandibular body or angle; prosthetic material

21127 Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining autograft


Orthognathic surgery is the surgical correction of abnormalities of the mandible (lower jaw), the maxilla (upper jaw), or both.  When orthognathic surgery is indicated, it is generally after orthodontic treatment (braces), which is done in order to move the teeth into their new position. 

During the surgical procedure, the jawbones are repositioned to a more “normal” position; in some cases, bone may be added, removed, or reshaped.  Surgical plates, screws, wires and rubber bands may be used to hold the jaws in their new position.  The most common technique is known as the LeFort I (though there are variations of this technique that may be performed, depending on the exact indications for the surgery).

Orthognathic surgery is usually performed by both an oral and maxillofacial surgeon and an orthodontist.  The orthodontist will work to position the teeth in proper alignment and the oral and maxillofacial surgeon does the surgery as needed on the jaw joints and/or other facial bones.

Coverage Limitations
Humana members may NOTbe eligible under the Plan for orthognathic surgeryfor any indications other than those listed above. This technology is considered experimental/investigational or NOT medically necessary if it is not utilized in accordance with nationally recognized standards of medical practice and/or identified as safe, widely used and generally accepted as effective for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

Humana members may NOTbe eligible under the Plan for 3-D Computerized Tomography (CT) scan, including in the pre-planning phase of treatment.  This technology is considered experimental/investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language

Criteria for a Coverage Determination as Reconstructive and Medically Necessary: 

A requested procedure will be deemed reconstructive and medically necessary and therefore covered when:

1. There is a physical abnormality and/or physiological abnormality that is causing a functional impairment that requires correction;and

2. The proposed treatment is of proven efficacy; and is deemed likely to significantly improve or restore the patient’s physiological function


Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service.The documentation requirements outline below are used to assess whether the member meets the clinical criteria for coverage but do not guarantee coverage of the service requested.

Medical notes documenting all of the following:

** Comprehensive  history of the medical condition(s) requiring treatment or surgical intervention; including all of the following:

A well-defined physical and/or physiological abnormality (e.g., congenital abnormality, functional or skeletal impairments) resulting in a medical condition that has required or requires treatment; The physical and/or physiological abnormality has resulted in a functional deficit; The functional deficit is recurrent or persistent in nature

** Appropriate clinical studies/tests including cephalometric tracings and analysis addressing the physical and/or physiological abnormality that confirm its presence and the degree to which it is causing impairment, with appropriate measurements, when applicable Radiologic film interpretations including lateral cephalometric  radiograph, AP radiograph and panoramic radiograph

** Clinical photographs of the member’s occlusion Diagnostic Polysomnography for obstructive sleep apnea surgery

** Treating physician’s plan of care including surgical treatment objectives, which must include the expected outcome for the improvement of the functional deficit

** History of previous non-surgical and surgical treatment (e.g.,obstructive sleep apnea


The following definitions may not apply to all plans. Refer to the member specific benefit plan document for applicable definitions.

Cancer Sequela: An aftereffect resulting from a cancer

Functional/Physical Impairment: A Physical/Functional or Physiological Impairment causes deviation from the normal function of a tissue or organ. This results in a significantly limited, impaired, or delayed capacity to move, coordinate actions, or perform physical activities and is exhibited by difficulties in one or more of the following areas: physical and motor tasks; independent movement; performing basic life functions.

Jaw Surgery: Surgical procedures to address facial trauma, neoplasms, facial clefts, surgical resection and iatrogenic radiation.

Orthognathic Surgery: The surgical correction of skeletal anomalies or malformations involving the mandible (lower jaw) or maxilla (upper jaw). These malformations may be present at birth or may become evident as the individual grows and develops. Causesinclude congenital or developmental anomalies.

Monday, July 1, 2019

CSHCS - Inital and ongoing comprehension evaluation basic


The Initial Comprehensive Evaluation is performed during the CSHCS client’s first visit to the CMDS clinic. The medical team integrates assessments and recommendations and works with the family/beneficiary in the development of a coordinated and comprehensive POC and treatment for the beneficiary. The CMDS POC is required to be recorded. The CMDS clinic will communicate the written CMDS POC to the appropriate health care providers and the family/beneficiary. Written CMDS POCs may be provided to other appropriate health care providers for whom the parent/guardian/beneficiary has signed a medical release form. A copy of the CMDS POC is to be submitted to CSHCS medical consultants for review.

An Initial Comprehensive Evaluation visit must include the following:

* Physician specialist(s) and non-physician professionals examination or assessment of the beneficiary and submission of an established/confirmed diagnosis(es), identification of strengths and needs and, with family/beneficiary input, development of a course of action or plan for treatment;

* Integration of findings and recommendations at team conferences;

* Discussion of the medical findings and treatment recommendations with family/beneficiary in language the family/beneficiary can comprehend;

* Designation of identified staff to teach the family/beneficiary how to assist in the management of the beneficiary’s health problems if appropriate; and

* Compilation of an integrated CMDS POC from the findings of the various health care providers that includes:

* relevant history;

* medical findings by specialty;

* problem areas that may develop and for which the beneficiary should receive care;

* recommendations and prescriptions for braces, shoes, special equipment, medications, etc.;

* referral to physical therapy, speech-language therapy, occupational therapy, public health nurse, CMDS support services; and

* a description of how the CMDS POC will be implemented. Authorization and processes may differ per health plans and Fee-for-Service (FFS).

Reimbursement for the Initial Comprehensive Evaluation fee occurs only once per beneficiary per lifetime regardless of the number of diagnoses and/or CMDS clinics from which the beneficiary may be receiving services. Medical services continue to be billed as usual.


Basic and ongoing comprehensive evaluation is conducted with established CMDS patients. The evaluation(s) may include the entire CMDS clinic staff composition or asdeemed appropriate by each CMDS clinic Medical Director per visit and is documented in  the CMDS POC.

A basic and ongoing comprehensive evaluation may include the following activities:

* Comprehensive beneficiary assessment;

* Evaluation and identification of the beneficiary’s needs;

* Coordination of the beneficiary’s multi-disciplinary needs;

* Review and modification of the comprehensive CMDS POC;

* Assured implementation and follow-up; and

* Referrals to other professionals, resources, and services as applicable.

Reimbursement for the Basic and Ongoing Comprehensive Evaluation fee is provided for a maximum of three (3) visits per beneficiary, per 12-month CSHCS eligibility year regardless of the number of diagnoses or CMDS clinics the beneficiary may have.

Medical services continue to be billed as usual.


Management/follow-up visits to a CMDS clinic may be provided if they are recommended in the CMDS POC. In addition, a referral may be recommended based on a tertiary hospital inpatient discharge plan that was written within the previous 12 months of the referral. Every effort should be made to include all staff identified as participants in theCMDS POC or as recommended by the CMDS clinic Medical Director.

The management/follow-up visit may include:

* A physical exam by a pediatrician and/or physician subspecialist(s);

* Assessment by at least two of the clinic staff (in addition to the clinic physicians) designated for the clinic type;

* Follow-up on all components identified in the CMDS POC by appropriate staff;

* Update of condition and treatment, and revision of the CMDS POC; and

* Communication with the family/beneficiary, other providers, and other designated health care providers, including provision of copies of the CMDS POC to the family/beneficiary.

Reimbursement for the management/follow-up visit clinic fee is provided for a maximum of three (3) visits per beneficiary, per 12-month CSHCS eligibility year, regardless of the number of diagnoses or CMDS clinics the beneficiary may have. Medical services continue to be billed as usual.


CMDS clinics may provide support services. Services consists of counseling, specialized training, transition assistance and/or treatment. Support services must be ordered as part of the CMDS POC developed at a CMDS Clinic Initial Comprehensive Evaluation, Basic and Ongoing Comprehensive Evaluation, and/or Management/Follow-up Visit. CMDS clinic support services may be provided by any combination of one or more of the non-physician basic CMDS clinic staff to the family/beneficiary as outlined in the CMDS POC. Support services may be conducted by professional members of the team (i.e., nurses, dietitians, certified diabetes counselors, social workers or other clinical professional staff as appropriate). The presence of a physician is not required.

* The clinical encounter must be substantive with clinical information gathered, treatment recommendations provided, transition needs addressed and an update to the CMDS POC.

* The clinical content of the encounter is documented in the CMDS POC.

CMDS support service visits include and provide two different methods of delivery:

* Face-to-Face meetings between the appropriate clinic professional and thefamily/beneficiary; or

* Telephone meetings between the appropriate clinic professional and the family/beneficiary.

Reimbursement for support services clinic fees can be provided up to a maximum of ten (10) visits per beneficiary as a single method or as a combination of methods, per 12- month CSHCS eligibility year, regardless of the number of diagnoses or CMDS clinics the beneficiary may have. Medical services continue to be billed as usual.


CMDS clinics must establish and maintain an agreement with each Medicaid and MIChild Health Plan for health plan enrolled beneficiaries to ensure coordinated care planning and data sharing.

* CMDS clinics must establish a process for clinical staff to communicate with health plan staff on a regular basis to identify health plan enrollees using the CMDS clinic(s), review testing/assessment/screening results, treatment plans, CMDS POCs, and status of mutually served beneficiaries.

* CMDS clinics must collaborate with health plans on the development of referral procedures and effective means of communicating the need for beneficiary-specific referrals. For beneficiaries enrolled in a health plan, CMDS clinics must bill the Medicaid Health Plan (MHP) for medical services rendered according to the health plan billing rules.

The CMDS clinic fee is billed as a FFS claim through CHAMPS regardless of health plan status.

CMDS clinic fees must be billed according to instructions contained in the Billing & Reimbursement for Professionals Chapter of this Manual. CMDS clinics must bill clinic fees following Uniform Billing (UB) guidelines on the professional CMS-1500 claim format or the electronic Health Care Claim Professional (837) ASC X12N version 5010 information. CHAMPS NPI claim editing will be applied to the billing, rendering, supervising, attending, servicing and referring providers as applicable for payment.

Explanation of Services

In addition to medical services, the CMDS Clinics provide:

• A single place and extended appointment for the family to be seen by their team of pediatric specialty providers as well other appropriate health care professionals during that one appointment;

• An environment where the providers come to the family for the single appointment at the clinic as opposed to the family needing to set separate dates and times to go to each provider as in the usual service methodology;

• Same day, face-to-face care coordination by all of the providers who have seen the beneficiary at that appointment allows for immediate discussion, negotiation, coordination and duty assignment of the decisions made that resulted from the provider meeting that follows the appointment. The family does not need to interpret information from one provider to the next which risks misunderstanding as in the usual
service methodology;

• Development and upkeep of a coordinated and comprehensive plan of care and treatment for beneficiaries including clear statements of current comprehensive assessment and ongoing treatment plans available to the entire team;

• Facilities that are tailored to the needs of children and their families; and

• Opportunity for the parent/beneficiary to participate in treatment planning, allowing for timely feedback and discussion of concerns with specialists and other health care professionals simultaneously when needed.

Friday, June 7, 2019

Medicare Diabetes Prevention Program (MDPP)

Expanded Model Fact Sheet Overview of MDPP

The MDPP expanded model includes an evidence-based set of services aimed to help prevent the onset of type 2 diabetes among Medicare beneficiaries with an indication of prediabetes. MDPP services will be available to eligible beneficiaries nationwide beginning April 1, 2018 under a performance-based payment model through the CMS Innovation Center.

Questions about MDPP

What is covered through the model?

• Structured sessions with a coach, using a CDC-approved curriculum to provide training in dietary change, increased physical activity, and weight loss strategies

• 12 months of core sessions for beneficiaries with an indication of prediabetes, and an additional 12 months of ongoing maintenance sessions for participants who meet weight loss and attendance goals.

How does the model pay for MDPP services?

MDPP suppliers are paid performance-based payments through the CMS claims system. Medicare payments to suppliers will range, and can be up to $670 per beneficiary over
2 years, depending on beneficiaries’ attendance and weight loss.

What does this mean for beneficiaries?
Beginning April 1, 2018, eligible beneficiaries have coverage of MDPP services with no costsharing through Medicare-enrolled MDPP suppliers.
Eligible beneficiaries are those who:
• Are enrolled in Medicare Part B
• Have a body mass index (BMI) of at least 25, or at least 23 if self-identified as Asian
• Meet 1 of the following 3 blood test requirements within the 12 months of the first core session:
    ? A hemoglobin A1c test with a value between 5.7 and 6.4% , or
    ? A fasting plasma glucose of 110-125 mg/dL, or
    ? A 2-hour plasma glucose of 140-199 mg/dL (oral glucose tolerance test)
• Have no previous diagnosis of type 1 or type 2 diabetes (other than gestational diabetes)
• Do not have end-stage renal disease (ESRD)

What does this mean for providers?

Although a referral from a physician is not required for beneficiaries to participate in MDPP services, clinicians have an important role to play in helping beneficiaries understand their risk of diabetes and their treatment options. This is particularly important because only 14% of adults aged 65 and older with prediabetes are aware of their condition. Clinicians may help Medicare patients obtain the blood tests they need to become aware of their risk and recommend they
participate in MDPP services.

What does this mean for organizations that wish to deliver MDPP services?

Organizations who wish to furnish MDPP services to beneficiaries and bill Medicare for those services must enroll in Medicare as an MDPP supplier.

To enroll as an MDPP supplier, organizations must:
• Have MDPP preliminary recognition or full CDC DPRP recognition
• Have an active and valid tax-identification number (TIN) or national provider identifier (NPI)
• Pass enrollment screening at the high categorical risk level
• On the MDPP enrollment application, submit a list of MDPP coaches who will lead sessions,including full name, date of birth, social security number (SSN), and active and valid NPI and coach eligibility end date (if applicable)
• Meet MDPP supplier standards and requirements, and other requirements of existing Medicare providers or suppliers
• Revalidate its enrollment every 5 years

Key Dates
• January 2018– MDPP supplier enrollment begins
• April 2018– Enrolled MDPP suppliers may begin furnishing services and billing Medicare

Centers for Disease Control and Prevention.
CDC twenty four seven. Saving Lives, Protecting People

National Diabetes Prevention Program
CDC-recognized lifestyle change programs are based on years of research showing that a year-long, structured lifestyle change intervention reduced the incidence of diabetes by 58% among adults with prediabetes and by 71% among those aged 60 years or older. The same study showed a 31% reduction with metformin compared with placebo. The researchers concluded that the lifestyle intervention was significantly more effective than metformin.

And the results last. Even after 10 years, people who completed a diabetes prevention lifestyle change program had a 34% lower rate of type 2 diabetes.

Participating in a program to lose weight through healthy eating and increased physical activity can also reduce the risk of heart attack and stroke.

Quality Standard

To ensure high-quality interventions, CDC only recognizes lifestyle change programs that meet evidence-based standards and show they can achieve results. These standards include:

• Following a CDC-approved curriculum
• Facilitation by a trained lifestyle coach
• Making regular data submission (according to the timeline dictated in the current DPRP Standards) to show that the program is having an impact.

Serious & Common

More than 84 million US adults—that’s 1 in 3—have prediabetes. With prediabetes, blood sugar is higher than normal but not high enough yet to be diagnosed as diabetes. People with prediabetes are at high risk for type 2 diabetes (the most common type of diabetes), heart disease, and stroke.

In the last 20 years, the number of adults diagnosed with diabetes has more than tripled as the US population has aged and become more overweight. Now more than 30 million Americans have diabetes, which increases their risk for a long list of serious health problems, including:

•Heart attack
•Kidney failure
•Loss of toes, feet, or legs
The good news: the CDC-led National Diabetes Prevention Program’s lifestyle change program can help people with prediabetes prevent or delay type 2 diabetes and other serious health problems and improve their overall health. It’s scientifically proven, and it works.

Diabetes Is Expensive
Diabetes has an enormous economic impact on millions of individuals and their families, on workplaces, and on the US health care system.

In 2017, the total estimated cost of diagnosed diabetes was $327 billion ($237 billion in direct medical costs and $90 billion in lost productivity), up 26% over a 5-year period.
About 1 in 4 health care dollars is spent on people with diagnosed diabetes.
Medical expenses for people diagnosed with diabetes—$16,750 annually on average—are about 2.3 times higher than for people without diabetes.

The Time To Act Is Now
Don’t let the “pre” in prediabetes fool you—prediabetes is a serious health condition that can develop into even more serious health conditions.

Program Eligibility

CDC-recognized lifestyle change programs are designed for patients who have prediabetes and are at high risk for developing type 2 diabetes.

Follow the guidelines below to know which patients are eligible for the program.
Which Patients to Refer
To be eligible for referral to a CDC-recognized lifestyle change program, patients must meet the following requirements:

•Be at least 18 years old and
•Be overweight (body mass index =25; =23 if Asian) and
•Have no previous diagnosis of type 1 or type 2 diabetes and
•Have a blood test result in the prediabetes range within the past year:
    •Hemoglobin A1C: 5.7%–6.4% or
    •Fasting plasma glucose: 100–125 mg/dL or
    •Two-hour plasma glucose (after a 75 gm glucose load): 140–199 mg/dL or
•Be previously diagnosed with gestational diabetes

Prediabetes can be diagnosed via oral glucose tolerance tests, fasting blood glucose tests, or an A1C test. Blood-based testing is the most accurate way to determine if a patient has prediabetes.

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