News
Flash:
Coordination of Diabetes Education and
Medical Nutrition Therapy Benefits is a Major Concern
Medicare wants to make 4 of the
10 hours on DSME to be on MNT!
Reimbursement
for Diabetes Self-Management Education
(DSME) is improving, although it remains an uphill battle. The
American Diabetes Association has always been and continues to be
at the fore-front of advocacy efforts to improve reimbursement.
As
you have seen, over the last few years in particular, the payer
landscape has been changing.
In 1997, Congress passed the Balanced Budget Act (BBA),
permitting Medicare coverage of outpatient DSME when services are
furnished by a certified provider who meets certain quality
standards.
It
took until 1999, before HCFA pro-posed rules for coverage, types
and frequency of training sessions, eligible patients, and
qualified providers. All major
national diabetes organizations sent comments and the final
rules, were published in the Federal Register on December 29,
2000, and they are now in effect.
They stipulate that coverage is available when the
physician treating the diabetes certifies that the services are
needed.
Services
are provided in group sessions unless language or physical
challenges, such as severely impaired hearing or sight, are
present. Patients
must be referred by a physician. Ten hours of initial DSME are
covered, including one hour for individualized assessment of
training needs. The remaining 9 hours are to be used for
instruction
in
the 10 content areas outlined in the National Standards for
Diabetes Self-Management Education.
Qualified
beneficiaries are those with new onset diabetes or poorly
controlled diabetes (as evidenced by glycated hemoglobin =8.5% in
the 90 days prior to training) as well as those who have, or are
at high risk for, diabetes- related complications. Two hours of
follow-up training per year are to be provided either in a group
or individual setting, if ordered by the patient’s primary care
provider.
Providers
must be certified by a nationally accredited body registered with
HCFA. Currently, only the American Diabetes Association Education
Recognition Program qualifies, although the door is open for other
organizations to become certifying entities.
New
Codes for billing outpatient DSME were created for both individual
and group sessions.
In
January 2002, new coverage for medical nutrition therapy (MNT)
provided by registered dietitians for Medicare patients with
diabetes and renal disease will be available. The proposed rule
for this coverage was published by the Centers for Medicare and
Medicaid Services (CMS), formerly HCFA, on August 2, 2001.
Comments were invited and due to CMS by October 1, 2001.
Well,
On November 1, 2001, the proposed regulations were published in
the Federal Register and unfortunately, despite the opinions of
the American Diabetes Association, The American Association of
Diabetes Educators, and The American Dietetic Association, the
three organizations considered to be experts in diabetes
education, the proposed regulation features “coordination” of
the new MNT benefit with the DSME benefits already in place.
This
“coordination of benefits” has been the major issue and many
intense discussions were held between ADA leadership, volunteers,
and staff, as well as with other diabetes organizations. From the
AADE the response to CMS emphasized that, DSME and MNT are two
distinct but complementary services and that a patient benefits
most by receiving both services within a reasonable time period or
even in an overlapping interval.
CMS
proposes to “coordinate” the new MNT benefit with the DSME
benefits for patients within a 12-month episode of care. This
means that, if MNT is delivered first, the number of hours used
for the MNT benefit would be deducted from the 10 hours of DSME
available. As yet, CMS has not determined the number of hours that
will be
allotted
to MNT. However, as an example, if MNT were allotted 4 hours (the
American Dietetic Association has advocated for 4.5 hours) and the
patient received those hours prior to coming to a DSME program,
DSME would receive reimbursement for only 6 hours.
In
similar fashion, the CMS regulation would combine the MNT and DSME
benefits in the following years by requiring MNT to be combined in
the 2-hour time frame heretofore allowed for DSME.
The
American Diabetes Association does not support this regulation. In
effect, this rule severely undermines the comprehensive diabetes
education coverage that Congress established in the BBA. Congress,
by passing the MNT provision, surely could not have intended that
the DSME programs would be diminished in this manner. The CMS
regulation, as currently written denies the person with diabetes
the comprehensive diabetes self-management education provided by
the BBA forces the patient and physician to take an either/or
stance regarding the educational needs of the patient
has
the potential to seriously impact reimbursement to ADA Recognized
Education Programs, giving rise to the potential of closing
programs across the country, thus reducing access to educational
services departs sharply from the intent of Congress and invites
further advocacy intervention by the American Diabetes Association
and others
This
is an extremely important issue, so stay tuned while AADE is
working to arrange a
face-to-face
meeting to discuss the situation.
We will keep you informed as
progress
is made, as well as contact you if grassroots lobbying is needed.
Coordination
of benefits continues to be the single
largest
issue for ADA.
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