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KMAP BULLETIN: Diabetes Self-Management Training

Date: 09/14/23

KMAP GENERAL BULLETIN 23241 (PDF)

Effective with dates of service on and after October 1, 2023, the Kansas Medical Assistance Program (KMAP) will cover Diabetes SelfManagement Training (DSMT), which is a preventive outpatient service for persons diagnosed with diabetes. An accredited outpatient DSMT program includes education on self-monitoring of blood glucose, diet and exercise, and an insulin treatment plan developed specifically for the patient who is insulin-dependent and motivates patients to use the skills for successful self-management of diabetes. DSMT services minimizes the occurrence of disease disability through instruction and maintaining the health and well-being of the patient. 

DSMT can be provided by providers who meet quality standards of the Center for Medicare & Medicaid Services (CMS) approved national accrediting organizations such as the American Diabetes Association (ADA) and the Association of Diabetes Care & Education Specialists (ADCES). Providers must append modifier U7 to codes G0108 and G0109 to indicate that they meet these quality standards. The claim must contain the National Provider Identifier (NPI) of both the rendering provider and the billing provider. 

The following Certified Diabetic Educator Professionals who may provide DSMT are listed below: 

  • Physician (31-000)
  • Advance Practice Nurse (09-093, 09-094, and 09-095)
  • Physician Assistant (10-100)
  • Hospital (01-010)
  • Clinic (08-080 and 08-081)

The medical professionals who may prescribe/refer patients for DSMT services include:

  • Physician (31-000)
  • Advance Practice Nurse (09-093, 09-094, and 09-095)
  • Physician Assistant (10-100)

Billing:
The following codes will be allowed for DSMT and will be reimbursed at 75% of the Medicare rate: 

  • G0108 - $40.26 per unit, 1 unit equals 30 minutes of training
  • G0109 - $11.11 per unit, 1 unit equals 30 minutes of training

The claim must contain a diagnosis code from the following range of diagnosis codes:

  • E08.00 - E13.9 – Diabetes Mellitus

Covered Services:
A physician or approved designee must order all diabetic DSMT services. DSMT services include: 

  • Diabetic overview/pathophysiology of diabetes
  • Nutrition
  • Exercise and activity
  • Diabetes medication (including skills related to the selfadministration of injectable drugs)
  • Self-monitoring and use of the results
  • Prevention, detection, and treatment of acute complications
  • Prevention, detection, and treatment of chronic complications
  • Foot, skin, and dental care
  • Behavior change strategies, goal setting, risk factor reduction, and problem-solving
  • Preconception care, pregnancy, and gestational diabetes
  • Relationships among nutrition, exercise, medication, and blood glucose levels
  • Stress and psychosocial adjustment
  • Family involvement and social support
  • Benefits, risks, and management options for improving glucose control
  • Use of health care systems and community resourcES

An approved entity must collect and record in an organized, systematic manner the following patient assessment information and medical information that includes the following:

  • Duration of the diabetic condition
  • Use of insulin or oral agents
  • Height and weight
  • Results and date of last HbA1C
  • Information on self-monitoring (frequency and results)
  • Blood pressure with the corresponding dates
  • Date of last eye exam
  • Educational goals
  • Assessment of educational needs
  • Training goals
  • Plan for follow-up assessment of achievement of training goals between 6 months and 1 year after the member completes the training

Limitation:
Allow a maximum of 6 hours of training in ½ hour units within a continuous 12-month period. This may be a combination of individual sessions or group sessions, not to exceed a combined total of 12 units per year. Services must be reasonable and necessary and are covered for both newly diagnosed individuals and those who need additional support/training for self-management of their diabetes. A diagnosis of diabetes must appear on the claim.

Note: The rates noted in this bulletin are subject to future changes. Providers should check the KMAP website for the most up-to-date rates.

Note: The effective date of the policy is October 1, 2023. The implementation of State policy by the KanCare Managed Care Organizations (MCOs) may vary from the date noted in the KMAP bulletins. The KanCare Open Claims Resolution Log on the KMAP Bulletins page documents the MCO system status for policy implementation and any associated reprocessing completion dates once the policy is implemented.