Page 283 - Medicare Benefit Policy Manual

o a random glucose test over 200 mg/dL for a person with symptoms of
uncontrolled diabetes.

Documentation that the beneficiary is diabetic is maintained in the beneficiary’s medical
record.

Beneficiaries are eligible to receive follow-up training each calendar year following the
year in which they have been certified as requiring initial training or they may receive
follow-up training when ordered even if Medicare does not have documentation that
initial training has been received. In that instance, contractors shall not deny the follow-
up service even though there is no initial training recorded.

300.2 - Certified Providers
(Rev. 109; Issued: 08-07-09; Effective Date: 03-30-09; Implementation Date: 09-
08-09)

A designated certified provider bills for DSMT provided by an accredited DSMT
program. Certified providers must submit a copy of their accreditation certificate to the
contractor. The statute states that a “certified provider” is a physician or other individual
or entity designated by the Secretary that, in addition to providing outpatient self-
management training services, provides other items and services for which payment may
be made under title XVIII, and meets certain quality standards. The CMS is designating
all providers and suppliers that bill Medicare for other individual services such as
hospital outpatient departments, renal dialysis facilities, physicians and durable medical
equipment suppliers as certified. All suppliers/providers who may bill for other Medicare
services or items and who represent a DSMT program that is accredited as meeting
quality standards can bill and receive payment for the entire DSMT program. Registered
dietitians are eligible to bill on behalf of an entire DSMT program on or after January 1,
2002, as long as the provider has obtained a Medicare provider number. A dietitian may
not be the sole provider of the DSMT service. There is an exception for rural areas. In a
rural area, an individual who is qualified as a registered dietitian and as a certified
diabetic educator who is currently certified by an organization approved by CMS may
furnish training and is deemed to meet the multidisciplinary team requirement.

The CMS will not reimburse services on a fee-for-service basis rendered to a beneficiary
under Part A.

NOTE: While separate payment is not made for this service to Rural Health Clinics
(RHCs), the service is covered but is considered included in the all-inclusive encounter
rate. Effective January 1, 2006, payment for DSMT provided in a Federally Qualified
Health Clinic (FQHC) that meets all of the requirements identified in Pub. 100-04,
chapter 18, section 120 may be made in addition to one other visit the beneficiary had
during the same day.

All DSMT programs must be accredited as meeting quality standards by a CMS approved
national accreditation organization. Currently, CMS recognizes the American Diabetes