To enter this program, patients have to have an HbA1c of at least 9%, a systolic blood pressure of at least 160 mm Hg, and an LDL cholesterol level of more than 140 mg/dL. Because it focuses on nonadherent, high-risk patients, this program has more clinical components.
When patients come in, they have some initial exams (blood pressure, foot, and retina screening) and get copies of their most recent labs, including HbA1c, blood pressure, and LDL cholesterol. After a group review of diabetes-care issues, the ancillary staff takes over. Diet and nutrition, erectile dysfunction, mood disorders, barriers to care – any of these topics, and more, can become fodder for discussion. Open-ended questions from the facilitators usually help establish the group discussion themes.
During group time, patients are individually called into a separate room to review their labs, set treatment goals, and have their medications titrated. “Yes, there is a huge educational component to it, but this is not just an education class,” Ms. Watts said. “I want more. I want those blood sugars, blood pressures, and LDL numbers under control.”
She started the program in 2003, and her early assessments indicate that most patients (who attend about two or three sessions) are able to reduce their HbA1c levels by 1%-2%. This improvement is directly related to increased medication adherence, Ms. Watts said.
Billing for the educational part of the SMA can be more than a little tricky, Ms. Hodorowicz said. “Medicare reimbursement for diabetes self-management training (DSMT) and medical nutrition therapy (MNT) is convoluted, confusing, complicated, and constantly changing.”
It's important to note that although Medicare does cover both DSMT and diabetes MNT, it will not pay for both when they are furnished on the same day to the same beneficiary. Although registered dieticians, certified diabetes educators, nurse practitioners, physician assistants, and others involved in the SMA can all bill for their services, either with their own national provider identification number or that of their group practice, Medicare requires some key codes for payment.
One of these is the five-digit diabetes ICD-9 diagnosis code. “This is really important on any claim you are billing,” she said. “Without a five-digit code to enhance the specificity of the diabetes diagnosis, you have a 99% chance that Medicare is going to deny that claim.”
For group DSMT, the procedure code is G0109, and time is billed in 30-minute units. But for this service to be covered by Medicare, the DSMT program has to be certified by the American Association of Diabetes Educators, the American Diabetes Association, or Indian Health Services.
Private payers also will cover group DSMT but may require different procedure codes. “It's best just to call them and ask what they want rather than guessing and getting a payment denied,” Ms. Hodorowicz said.
The procedure code for group diabetes MNT is 97804. Again, time is billed in 30-minute units. Registered dieticians who are Medicare providers are the only individuals who can furnish diabetes MNT and be reimbursed, although private practices, outpatient hospital departments, and some other entities also can bill on behalf of the dietician. Again, many private payers do cover MNT, but might require different procedure codes.
The SMA is an evidence-based practice paradigm that can work well for everyone involved, Ms. Hodorowicz said. “It's a highly effective way to deliver quality follow-up medical care and quality self-management education.”
Ms. Hodorowicz is on the faculty of the Johnson & Johnson Diabetes Institute, San Jose, Calif., and the DASPA (Diabetes Accreditation Standards–Practical Applications) program, which is sponsored jointly by the National Community Pharmacists Association and the American Association of Diabetes Educators; she also is on the speakers bureau of Nestle HealthCare Nutrition. Dr. Cornell is on the speakers bureau of Merck & Co. Inc., Abbott Diabetes Care, Novo Nordisk, the Johnson & Johnson Diabetes Institute, and Takeda Pharmaceutical Co.
Resources: A manual written by Ms. Watts describes how to establish and run a diabetes SMA program. Requests for the manual can be made to her at sharon.watts@va.govwww.maryannhodorowicz.comhodorowicz@comcast.net
Session at DuPage Community Clinic in Wheaton, Ill. (L-R) Sarah Slater, pharmacy student 3rd year, and Tony Appello, pharmacy student 3rd year, presenting.
Source Courtesy Susan Cornell