The HME industry is constantly changing. Suppliers are being asked to do more for beneficiaries with less reimbursement.

The recent delay of competitive bidding comes as a mixed blessing. Instead of competitive bidding with price reductions in 10 MSAs, the products previously subject to competitive bidding are now subject to a nationwide fee reduction of 9.5%. This fee reduction affects everyone, and will begin on January 1, 2009.

To succeed, an HME supplier must look for creative ways to increase revenue. Individuals who have been newly diagnosed with diabetes need to be educated about how to live with the disease.

Medicare reimburses for diabetes self-management training (DSMT). While adding DSMT services seems like a logical extension of business for a diabetic supplier, you should proceed with caution. Before taking the leap, understand the requirements necessary for reimbursement.

REIMBURSEMENT AND CONDITIONS OF COVERAGE

Medicare reimburses for DSMT for Medicare beneficiaries with diabetes under the physician fee schedule. DSMT is reimbursed when performed in an individual or group setting. Reimbursement is paid in 30-minute intervals, and there are special requirements for individual training. Training is categorized into initial training and follow-up training. Medicare covers, at most, 10 hours of initial training under the following conditions:

1. the beneficiary has not previously received initial or follow-up training;
2. training occurs within a continuous 12-month period;
3. training is usually furnished in a group setting, which can contain patients other than Medicare beneficiaries; and
4. 1 hour may be used for individual training, which may cover any part of the training.

The initial training does not need to occur in one session, but must occur within 12 months of the first session to qualify as initial training. Once a beneficiary has had initial training, all other training for that beneficiary is considered follow-up. Medicare covers at most 2 hours of follow-up training annually under the following conditions:

1. group training consists of two to 20 individuals who need not all be Medicare beneficiaries; and
2. the treating physician must document in the beneficiary's medical record that the beneficiary has diabetes.

Medicare covers individual training under any of the following conditions:

1. no group session is available within 2 months of the date training is ordered;
2. the beneficiary has a special need (documented in the medical record by the treating physician or qualified non-physician practitioner) resulting from conditions that would hinder effective participation in a group session (visual impairment, language limitations); or
3. the treating physician orders additional insulin training.

The treating physician must identify the need for individual training in their referral. In the event the carrier or fiscal intermediary determines individual training should have been conducted as group training, the claim will be "down-coded" and reimbursed at the down-code rather than denied.

BECOMING A CERTIFIED PROVIDER

DSMT may be furnished by any Medicare-enrolled person who:

1. furnishes other items or services reimbursed by Medicare;
2. may receive payments under the assignment and reassignment rules;
3. is accredited by an accreditation organization approved by CMS; and
4. provides documentation to CMS as requested, including diabetes outcome measurements.

A supplier may be reimbursed for DSMT. However, DSMT is not reimbursed through the DME MAC. Instead, it is reimbursed through local carriers, which means a supplier must obtain a provider number through a local carrier to bill for these services.

In addition to the usual requirements for DMEPOS suppliers to enroll in Medicare, the DSMT program provided by the DMEPOS supplier must be accredited. CMS currently recognizes accreditation of the DSMT program by the American Diabetes Association (ADA) and Indian Health Service (IHS). The accreditation organization may accredit an entity to meet one of three quality standards: CMS' quality standards (42 CFR § 410.144(a)), the National Standards for Diabetes Self-Management Education Programs (NSDSMEP), or standards of a national accreditation organization that represents individuals with diabetes. The ADA conducts accreditation for DSMT programs through its Education Recognition Program, available at professional.diabetes.org/~.

METHOD OF TRAINING

Again, the method of training may vary depending on the quality standard with which the DSMT supplier is accredited. The CMS quality standards for methods of training, 42 CFR § 410.144(6):

1. offer individual and group instruction for effective training;
2. use instructional methods and materials that are appropriate for the target population, and participants being served; and
3. use primarily interactive, collaborative, skill-based training methods, and maximize the use of interactive training methods.

The CMS quality standards, however, also require a "team approach" to training. The team approach, except as provided in paragraph (a)(4)(ii) of this section for a rural area, furnishes services using a multidisciplinary instructional team that meets the following requirements:

1. The team includes at least a registered dietitian, as recognized under state law, and a certified diabetes educator (CDE), certified by a qualified organization that has registered with CMS, who have didactic experience and knowledge of diabetes clinical and educational issues.
2. The team is qualified to teach the training content areas required in paragraph (a)(5) of this section.
3. All appropriate team members must be present during the portion of the training for which they are responsible, and must directly furnish the training within the scope of their practices.

In a rural area, an individual who is qualified as a registered dietitian and as a CDE, who is currently certified by an organization approved by CMS (or until February 27, 2004, an individual who is qualified as a registered dietitian and as a registered nurse), may furnish training and is deemed to meet the multidisciplinary team requirement in paragraph (a)(4)(i) of this section.

REPORTING REQUIREMENTS

A DSMT supplier must collect and record certain patient assessment information on a quarterly basis for each beneficiary receiving DSMT, and make information available to CMS upon request.

Denise M. Fletcher

1. Medical information should include the following:
   1. duration of the diabetic condition;
   2. use of insulin or oral agents;
   3. height and weight by date;
   4. results and date of last lipid test;
   5. results and date of last HbA1C;
   6. information on self-monitoring (frequency and results);
   7. blood pressure with the corresponding dates; and
   8. date of the last eye exam.
2. Other information should include:
   1. educational goals;
   2. assessment of educational needs;
   3. training goals;
   4. plan for a follow-up assessment of achievement of training goals between 6 months and 1 year after the beneficiary completes the training; and
   5. documentation of the training goals assessment.

It is logical for a diabetic supplier to consider providing DSMT services. However, Medicare has many requirements that must be met for a provider to be reimbursed. It is not as simple as simply stocking an additional product line. Before proceeding, make sure you can meet all the training requirements and you have secured all the appropriate billing numbers.

Denise M. Fletcher, JD, is an attorney with the Health Care Group at Brown & Fortunato PC, a law firm based in Amarillo, Tex. She represents pharmacies, infusion companies, HME companies, and other health care providers throughout the United States. Fletcher is Board Certified in Health Law by the Texas Board of Legal Specialization, and can be reached via e-mail: .