MDPP Suppliers’ Guide to Success

MDPP Suppliers’ Guide to Success

Diabetes affects more than 30 million people in the United States. In fact, 25 percent of Americans age 65 and older suffer from diabetes, and its prevalence continues to grow as 1.5 million Americans are diagnosed with this deadly disease every year, according to the American Diabetes Association. Your organization can be a part of the movement to prevent diabetes by becoming a Medicare Diabetes Prevention Program (MDPP) supplier.

In my July 17 blog post Medicare Diabetes Prevention Program: Coding Pre-Diabetes Services, I discussed the Centers for Medicare & Medicaid Services’ (CMS) novel program aimed at helping patients achieve weight loss, and in turn, reducing their risk of developing type 2 diabetes.

MDPP is a health behavior change intervention comprised of core sessions given over six months in a group-based setting. These coach-led structured sessions use a Centers for Disease Control and Prevention (CDC)-approved curriculum that provides training in dietary changes, increased physical activity, and strategies for weight control. Following the completion of the core sessions, patients may be eligible for additional monthly meetings to help ensure the maintenance of healthy behaviors.

Organizations who wish to furnish MDPP services to patients and bill Medicare for those services must enroll in Medicare as an MDPP supplier. Medicare pays MDPP suppliers to furnish group-based intervention to at-risk Medicare patients in sessions delivered for up to two years for eligible beneficiaries. Lets breakdown how to become an MDPP supplier and bill for services rendered.

How to Become a Medicare Enrolled MDPP Supplier

To enroll as an MDPP supplier, organizations must:

  • Obtain CDC preliminary or full DPRP recognition: it takes at least 12 months to obtain preliminary recognition and up to 24 additional months to achieve full recognition
  • Prepare for Medicare enrollment
    • Have an active and valid tax identification number (TIN) or national provider identifier (NPI)
    • Pass enrollment screening at the high categorical risk level
    • see the Enrollment Fact Sheet and Checklist
  • Apply to become a Medicare-enrolled MDPP supplier (existing Medicare providers must re-enroll)
    • Obtaining a separate NPI for MDPP enrollment strongly encouraged; claim rejections and denials may occur if multiple enrollments are associated with a single NPI.
    • 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 an active and valid NPI and coach eligibility end date (if applicable)
    • See the Enrollment Webinar Recording and Enrollment Tutorial Video
  • Furnish MDPP services
    • Make sure to meet MDPP supplier standards and requirements, and other requirements of existing Medicare providers or suppliers
    • See the Session Journey Map
  • Submit claims to Medicare
  • Re-validate its enrollment every 5 years

How Do I Bill for MDPP Services?

Medicare-enrolled MDPP suppliers can use the Quick Reference Guide to Payment and Billing and the Billing and Claims Fact Sheet for information on valid claims:

  • MDPP Medicare beneficiary eligibility data is returned via the HIPAA Eligibility Transaction System (HETS) on the 271 response; use this data to determine if a patient meets the criteria to receive MDPP services
  • Submit claims when a performance goal is met, and report codes only once per eligible beneficiary (except G9890 and G9891)
  • List each HCPCS code with the corresponding session date of service and the coach’s NPI
  • List all HCPCS codes associated with a performance payment (including non-payable codes) on the same claim
  • Include Demo code 82 in block 19 (Loop 2300 segment REF01 (P4) and segment REF02 (82)) to identify MDPP services
  • Do not include codes for other, non-MDPP services on the same claim

Some MDPP claims are being denied as a result of a systems issue. Medicare Administrative Contractors (MACs) are manually processing these claims through October 2019 until they implement the fix. Contact your MAC with questions

For a claim to be valid under the Medicare Diabetes Prevention Program (MDPP), you must have both:

  • Centers for Disease Control and Prevention (CDC) preliminary or full recognition
  • Separate Medicare enrollment as an MDPP supplier (Specialty D1)

If you do not have a separate Medicare enrollment as an MDPP supplier and you submit a claim for MDPP services, your claim will be rejected.

Stacy Chaplain

Stacy Chaplain

Stacy Chaplain, MD, CPC, is an executive editor at AAPC. Prior to her work at AAPC, she worked as Director of Clinical Coding Quality and has more than 4 years experience in medical writing & editing. Stacy received her Bachelor of Arts in Biology from The University of Texas at Austin and her Medical Doctorate from The University of Texas Medical Branch in Galveston. She is a member of the Beaverton, Oregon local chapter.

Stacy Chaplain

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Stacy Chaplain, MD, CPC, is an executive editor at AAPC. Prior to her work at AAPC, she worked as Director of Clinical Coding Quality and has more than 4 years experience in medical writing & editing. Stacy received her Bachelor of Arts in Biology from The University of Texas at Austin and her Medical Doctorate from The University of Texas Medical Branch in Galveston. She is a member of the Beaverton, Oregon local chapter.

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