4 Steps to Starting a Medicare Diabetes Prevention Program at Your Practice

As physicians continue to search for opportunities to lower healthcare costs and improve the quality of care they provide, they need look no further than diabetes, a condition on which more than one of every five healthcare dollars is spent, according to the American Diabetes Association. Annually, 1.4 million Americans are newly-diagnosed with diabetes, and it’s currently the seventh leading cause of death in the United States, according to the Centers for Disease Control and Prevention (CDC).

1.4 million Americans are newly-diagnosed with diabetes each year.


Diabetic complications are what drive up the costs associated with treating these patients, said Sheri Poe Bernard, CPC, COC, CDEO, CCS-P, of Poe Bernard Consulting and vice president of clinical coding content at AAPC, during her presentation at HEALTHCON 2017 in May. “There’s not a system that’s isn’t affected by the damage that diabetes does to circulation and the micro-vessels throughout the body,” Bernard told attendees. To help patients achieve better outcomes, physicians must make a concerted effort to coordinate care with specialists and address each patient’s diabetic complications, she said.

Creating a Medicare Diabetes Prevention Program (MDPP) is one of the many ways in which physicians coordinate care more effectively, said Bernard. The goal of an MDPP is to provide structural behavioral change intervention that ultimately prevents the onset of Type 2 diabetes among Medicare beneficiaries diagnosed with pre-diabetes. Medicare will begin paying for MDPP services as of January 2018, and there will be no cost for Medicare beneficiaries who meet certain participation criteria. Medicare will announce specific physician payment amounts sometime this year.

“It’s time to start thinking about whether you want your practice to have one of these programs,” said Bernard. “If you’re not going to have your own in-house program, you need to figure out where you’re going to send your patients so they can get the services that they’re entitled to as Medicare patients.”

Following are four steps to start an MDPP program:

1. Know what the MDPP benefit includes.

The MDPP includes a 12-month intervention with at least 16 weekly hour-long sessions throughout the first six months, followed by at least six monthly maintenance sessions for the remainder of the year. The first 16 sessions address topics such as:

  • self-monitoring of weight
  • food intake
  • overcoming barriers to success
  • balancing intake and output
  • aerobic fitness, and more 

Beneficiaries also have access to ongoing maintenance sessions every three months after the initial 12-month program if they achieve and maintain a 5% weight loss in the preceding three months.

2. Determine who will provide the MDPP services.

Eligible providers include trained community coaches or health professionals who are enrolled in Medicare with an active and valid national provider identifier. The practice or other organization providing MDPP services must also comply with standards and requirements for recognition by the CDC

3. Create a multi-disciplinary diabetes support team.

Bernard said that this team should include physician assistants, nurse practitioners, dieticians, certified diabetes educators, social workers, mental health professionals, dental care professionals, podiatrists, ophthalmologists, pharmacists, and other specialists. “These support teams can really reduce the duplicity of testing,” she added. Specialists can also help facilitate diabetes management, lower the risk of chronic disease complications, and provide patient education.

Patients and specialists don’t necessarily need to be in the same geographic area, said Bernard. “Telemedicine can be an incredible advantage,” she added. Real-time dietary counseling, remote monitoring of blood glucose and blood pressures, and real-time video conferencing for group education are just a few examples of how telehealth can benefit patients with diabetes.

4. Start screening patients for pre-diabetes.

Screening for pre-diabetes is an important step that physicians can take to prepare for an MDPP, said Bernard. Adult screening begins at age 45. It’s also appropriate for adults with a body mass index (BMI) greater than 25 (or greater than 23 in Asian Americans) or those who have other risk factors, such as dyslipidemia, high triglycerides, low HDL, or hypertension).

Coding Tips for Diabetes 

When the purpose of the encounter is to screen for pre-diabetes, report ICD-10-CM code Z13.1 and one of the following CPT codes, said Bernard:

  • CPT code 82947 (glucose; quantitative, blood) (except reagent strip)
  • CPT code 82950 (glucose; post-glucose dose) (includes glucose)
  • CPT code 82951 (glucose; tolerance test, three specimens) (includes glucose)

If the patient already has pre-diabetes, and the purpose of the visit is to follow-up with the pre-diabetes, append modifier -TS to the appropriate CPT code, she added.

Other at-risk patients to target include those with a family history of diabetes, a history of gestational diabetes, patients who aren’t physically active, those with polycystic ovarian syndrome, and others.

Remember to:

  • Specify Type 1 or Type 2
  • Include all complications and manifestations of diabetes (e.g., hyperglycemia, hypoglycemia, nephropathy, chronic kidney disease, retinopathy). Note that ICD-10-CM assumes a causal relationship between the diabetes and certain complications even in the absence of explicit documentation. When there is no link, physicians should document that the two conditions are not related. For example, a patient presents with diabetes and cataracts. When the cataracts are due to an injury (and not the diabetes), the physician should indicate that the injury caused the cataracts. Otherwise, a coder will assign a code for diabetic cataract, artificially inflating the patient’s risk-adjustment score.
  • Document all chronic conditions that affect the patient’s diabetic care, as this can help justify not only a higher evaluation and management code but also a higher risk-adjustment score.


To learn more about the MDPP,  listen to this CMS webinar.

About the Author

Lisa A. Eramo, BA, MA is a freelance writer specializing in health information management, medical coding, and regulatory topics. She began her healthcare career as a...

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