Date: July 29, 2022
To: All Medical Assistance Program Providers
Re: Billing Update for Diabetes Prevention and Management Programs
This notice provides additional billing guidance to diabetes prevention and management programs. These programs are available to customers covered under Medicaid fee-for-service (FFS) and the HealthChoice Illinois (HCI) managed care organization (MCO) plans.
As first announced in the informational notice dated August 20, 2021, these programs may enroll and the Department will provide coverage and reimbursement related to two nationally recognized programs described below:
- Diabetes Prevention Program (DPP)
The National Diabetes Prevention Program (DPP) is a yearlong, evidence-based lifestyle change intervention developed by the Centers for Disease Control and Prevention (CDC) to reduce the risk of adults with prediabetes progressing to Type 2 diabetes. The program achieves that goal primarily through weight loss that results from the CDC's Diabetes Prevention Lifestyle Change curriculum, which focuses on healthy eating, increasing physical activity, and managing stress. CDC-recognized DPP organizations may enroll as an Illinois Medicaid provider to administer the program to deliver a set of medically necessary services to prevent or delay the onset of Type 2 diabetes for beneficiaries with indications of prediabetes. DPP services are provided in-person or via telehealth/virtually during sessions that occur at regular, periodic intervals over the course of one year.
- Diabetes Self-Management Education and Support (DSMES)
Diabetes Self-Management Education and Support (DSMES) services are provided as preventive services and must be recommended by a physician or other licensed practitioner of the healing arts within his or her scope of practice under state law to prevent diabetes or the progression of diabetes, prolong life, and/or promote the physical and mental health of the beneficiary.
Services may be provided in the home, clinic, hospital outpatient facility, via telehealth, or any other setting as authorized and include: counseling related to long-term dietary change, increased physical activity, and behavior change strategies for weight control; counseling and skill building to facilitate the knowledge, skill and ability necessary for diabetes self-care; and nutritional counseling services.
Eligible customers may receive up to 18 hours of DSMES services during each 12-month period beginning with the initial training date, including:
- Up to three hours of individual DSMES, and
- Up to fifteen hours of group DSMES
Updates from the initial August 20, 2021, diabetes management provider notice:
- HFS no longer accepts paper claims. Per the November 24, 2021, provider notice, all claims and attachments must now be submitted electronically.
- Neither diabetes management program will require a formal referral. In accordance with HFS' approved State Plan Amendment language, the services need only be recommended. HFS will not require the National Provider Identifier (NPI) of an ordering/referring practitioner on the 837P claim form.
- Place of Service Codes 19 (Off Campus Outpatient Hospital) and 22 (On Campus Outpatient Hospital) have been added as valid places of service for diabetes management programs.
- New Modifier 93 - Synchronous Telemedicine Service rendered via telephone or other real-time interactive audio-only telecommunications system, is billable effective with dates of service beginning July 1, 2022. Refer to informational notices dated March 31, 2022, and March 21, 2022.
- New Place of Service Code 10 - Telehealth Provided in Patient's Home is also effective with dates of service beginning July 1, 2022. Please refer to the same March 2022 informational notices above.
Questions regarding this notice may be directed to the Bureau of Professional and Ancillary Services at 877-782-5565 for the FFS program, or the applicable HCI MCO.
Kelly Cunningham, Administrator
Division of Medical Programs