Page 286 - Medicare Benefit Policy Manual

such special conditions as identified by the treating physician or non-physician
practitioner, that will hinder effective participation in a group training session; or

• The physician orders additional insulin training.

• The need for individual training must be identified by the physician or non-
physician practitioner in the referral.

NOTE: If individual training has been provided to a Medicare beneficiary and
subsequently the A/B MAC (A) or (B) determines that training should have been
provided in a group, A/B MACs (A) and (B) down-code the reimbursement from
individual to the group level and provider education would be the appropriate
actions instead of denying the service as billed.

300.4.1 – Incident-To Provision
(Rev. 13, 05-13-04)

The “incident to” requirements of section 1861(s)(2)(A) of the Social Security Act do not
apply to DSMT services. Section 1861 (s)(2)(S) of the Act authorizes DSMT in a stand
alone provision. DSMT services are covered only if the physician or qualified non-
physician practitioner who is managing the beneficiary’s diabetic condition certifies that
such services are needed and refers the patient to the DSMT program. The referral must
be done under a comprehensive plan of care related to the beneficiary’s diabetic
condition. Training may be furnished by a physician, individual, or entity that meets the
following conditions:

• Furnishes other services for which direct Medicare payment may be made;

• May properly receive Medicare payment under 42CFR 424.73 or 424.80
which set forth prohibitions on assignment and reassignment of claims;

• Submits necessary documentation to, and is accredited by, an accreditation
organization approved by CMS under 42CFR 410.142 to meet one of the sets
of quality standards described in 42 CFR 410.144; and

Provides documentation to CMS, as requested, including diabetes outcome
measurements set forth at CFR 410.146.

Any certified providers or suppliers that provide other individual items or services under
Medicare that meet CMS’s quality standards and meet the conditions for CMS approval
pursuant to 42 CFR 410.145, may receive reimbursement for diabetes training. Entities
are more likely than individuals to bill for DSMT services. These certified providers
must be currently receiving payment for other Medicare services.

300.5 - Payment for DSMT
(Rev. 72, Issued: 05-25-07; Effective: 07-01-07; Implementation: 07-02-07)