CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Diabetes Prevention Program Coverage Summary and Payment Policy – Archive 1

Defines Neighborhood Health Plan of Rhode Island's coverage, eligibility, documentation, coding, payment, and billing rules for CDC-approved MDPP services for the INTEGRITY line of business, consistent with 42 CFR §424.205 and CMS guidance.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDiabetes Prevention Program Coverage Summary and Payment Policy – Archive 1

Policy CodePolicy N/A

Change TypeInitial creation (4/1/2018)

Effective Date

Next Review Date

Key ActionCreate and maintain a treatment record for each member receiving MDPP services containing member ID, documentation of medical necessity, type of session, coach, date/place of service, and weight at each session; ensure records are signed within 30 days and available upon request.

SourceLink

POLICY UPDATE CHANGES

Policy created on 4/1/2018.

1Lifetime limit for MDPP services

5%Minimum BMI reduction for ongoing maintenance coverage

5% / 9%Performance incentive thresholds

30 daysMax time to complete record signature

Scope: Defines Neighborhood Health Plan of Rhode Island's coverage, eligibility, documentation, coding, payment, and billing rules for CDC-approved Medicare Diabetes Prevention Program (MDPP) services for the INTEGRITY line of business, consistent with 42 CFR §424.205 and CMS guidance.

Overview: MDPP provides ongoing health behavior coaching and education to members at risk for type II diabetes and is covered with criteria. Services are delivered by CMS/CDC-recognized MDPP suppliers using a CDC-approved curriculum, reimbursed Fee-For-Service per provider contract, and subject to documentation and coding rules. Lifetime limit: MDPP services are limited to once per lifetime.

Quick policy thresholds and facts

Lifetime limitMDPP services limited to once per lifetime

BMI threshold>= 25 on date of first core session (>= 23 if self-identified as Asian)

Performance incentives5% and 9% weight-loss thresholds (G9880 = 5%; G9881 = 9%)

BMI measurement noteBMI reduction/performance measured from recorded weight at the first core session

Max time to complete record signatureTreatment records must be signed no later than 30 days from date of service

Medical Necessity Criteria

General Medical Necessity

All services must be medically necessary to qualify for reimbursement. Members must meet the following criteria:

ALL of the following

Member is enrolled in Neighborhood's INTEGRITY line of business and covered by the plan at time of service
Policy applies to INTEGRITY line of business for services under 42 CFR §424.205
Member does not have a diagnosis of diabetes prior to the date of the first core session
Gestational diabetes is an exception (does not preclude participation)
Member has not previously received MDPP services
MDPP services have a maximum limit of once per lifetime
Member meets session-specific clinical eligibility (see MDPP Core Sessions node)

MDPP Core Sessions (months 0-6) eligibility

Covered when ALL of the following are met:

ALL of the following

BMI threshold: Body Mass Index (BMI) of at least 25 on the date of the first core session>= 25 (>= 23 if self-identified as Asian)
BMI threshold is 23 if self-identified as Asian
Blood test ONE-of
- ONE of: Hemoglobin A1c test with a value between 5.7% and 6.4%5.7% - 6.4% (within 12 months prior to first core session)
- Fasting plasma glucose of 110-125 mg/dL

MDPP Ongoing Maintenance Sessions (months 13-24) eligibility

Covered when ALL of the following are met:

ALL of the following

Minimum reduction: Member achieved a minimum 5% BMI reduction based on initial session weight>= 5% reduction from baseline
BMI reduction is measured from the recorded weight of the first core session
Maintenance: Member maintains 5% BMI reduction for the duration of Ongoing Maintenance sessionsMaintain >= 5% reduction
Ongoing maintenance sessions are only covered if weight loss and attendance goals required by the program are achieved and maintained
Coverage condition:

MDPP Core Maintenance Sessions (months 7-12)

Coverage tied to attendance and whether weight-loss goal was achieved or maintained during core sessions

ANY of the following

Attendance and weight-goal linkage: Core maintenance sessions in months 7-9 and months 10-12 are covered per CMS definitions and corresponding HCPCS G-codes; coverage and payment vary depending on attendance and whether weight-loss goal was achieved or maintained
CMS-defined coverage distinctions and corresponding HCPCS G-codes exist for attendance-based and weight-goal dependent codes (see coding list)

Exclusions / Not Covered

MDPP services are not covered for members meeting any of the following

ANY of the following

Pre-existing diabetes: Members with a diagnosis of diabetes prior to the start date of the first core session
Gestational diabetes is an exception per eligibility guidance
ESRD: Members with a diagnosis of End Stage Renal Disease (ESRD)
Not INTEGRITY: Members not covered by the INTEGRITY line of business
Policy applies to INTEGRITY line of business for services under 42 CFR §424.205
Prior MDPP:

Coding

Covered MDPP HCPCS G-codes (attendance, maintenance, ongoing, performance incentives, bridge, session reporting)HCPCSCovered

G9873	1st core session attended
G9874	4 total core sessions attended
G9875	9 total core sessions attended
G9876	2 core maintenance sessions attended in months 7-9 (weight loss goal not achieved or maintained)
G9877	2 core maintenance sessions attended in months 10-12 (weight loss goal not achieved or maintained)
G9878	2 core maintenance sessions attended in months 7-9 and weight loss goal achieved or maintained
G9879	2 core maintenance sessions attended in months 10-12 and weight loss goal achieved or maintained
G9882	2 ongoing maintenance sessions attended in months 13-15 and weight loss goal maintained
G9883	2 ongoing maintenance sessions attended in months 16-18 and weight loss goal maintained
G9884	2 ongoing maintenance sessions attended in months 19-21 and weight loss goal maintained

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Provider Actions & Billing Rules

Documentation Required

Create and maintain treatment record

Create a treatment record for each member receiving MDPP services containing the required elements. Records must be accurate, legible, and signed within 30 days; available upon request.

Member identification (Neighborhood ID, name)
Documentation of medical necessity
Type of session (core, core maintenance, ongoing maintenance)
Coach leading the session
Date and place of service
Recording of member's weight at each session
Record signature completed no later than 30 days from date of service

Billing Rule

Claim forms and formats

Submit MDPP claims on a CMS-1500 Professional claim form or via electronic X12 837P. Adjustments, corrections, and reconsiderations must include required forms and meet timely filing requirements.

CMS-1500 Professional claim form
Electronic X12 837P format
Adjustments/corrections/reconsiderations must include required forms and meet timely filing requirements

Billing Rule

Performance incentive billing

Performance incentive codes G9880 (5% weight loss) and G9881 (9% weight loss) are billed as a second claim line with the sessions for each session the member maintains the weight loss. BMI reduction is measured from the recorded weight of the first core session.

Use G9880 for 5% weight loss performance incentive
Use G9881 for 9% weight loss performance incentive
Bill incentive codes as a second claim line with the session line(s)
BMI reduction measured from weight at first core session

Billing Rule

Make-up sessions modifier

Make-up sessions may be billed with modifier 'VM' in accordance with CMS guidelines.

Apply modifier VM to make-up session line items per CMS guidance

Prior Authorization

Prior authorization not required

MDPP services do not require prior authorization.

Denial Risk

Denial for ineligible members

Claims may be denied if the member is ineligible or documentation/medical necessity requirements are not met. Denial conditions include diabetes diagnosed prior to the first core session, End Stage Renal Disease (ESRD), not being covered by the INTEGRITY line of business, or previous receipt of MDPP services (once-per-lifetime limit).

Member had diabetes prior to the date of the first core session
Member has a diagnosis of End Stage Renal Disease (ESRD)
Member is not covered by INTEGRITY line of business
Member previously received MDPP services (maximum once per lifetime)
Required medical necessity or documentation elements are missing or inadequate

Documentation Required

Record amendment compliance

Any additions, deletions, modifications, or edits to treatment records must comply with Chapter 3 of the CMS Medicare Program Integrity Manual.

Background, Definitions & FAQs

MDPP is delivered in a structured sequence of sessions: Core Sessions (months 0-6), Core Maintenance Sessions (months 7-12), and Ongoing Maintenance Sessions (months 13-24). Core sessions in the first year are covered based on member attendance; ongoing maintenance sessions are covered only if the member achieves and maintains required weight-loss and attendance goals.

Suppliers must hold one of the recognized MDPP/CDC DPRP recognition statuses: MDPP Interim Preliminary Recognition, MDPP Preliminary Recognition, CDC Preliminary Recognition, or CDC Full Recognition, and all sessions must be delivered by an eligible MDPP coach using a CDC-approved curriculum.

Neighborhood reimburses MDPP claims Fee-For-Service per contract and follows CMS guidance for coding and billing. Providers must create and maintain a treatment record for each member that documents member ID, medical necessity, session type, coach, date/place of service, and weight at each session; records must be accurate, legible, and signed no later than 30 days from the date of service.

Term	Definition
MDPP
Medicare Diabetes Prevention Program
INTEGRITY
Neighborhood Health Plan of Rhode Island line of business to which this policy applies
CDC DPRP recognition
Supplier recognition statuses: MDPP Interim Preliminary Recognition; MDPP Preliminary Recognition; CDC Preliminary Recognition; CDC Full Recognition

Q: Is prior authorization required for MDPP services? A: No; MDPP services do not require prior authorization.

Q: Are members responsible for cost sharing for MDPP? A: No; cost sharing obligations such as coinsurance, copays, deductibles, or patient share do not apply to MDPP.

Q: How is BMI reduction measured for incentives? A: BMI reduction is measured from the recorded weight of the first core session.

Name	Type	Number	Effective Date
Requirements for Medicare Diabetes Prevention Program Suppliers
NCD

OpenPayer

Diabetes Prevention Program Coverage Summary and Payment Policy – Archive 1

Coverage Summary

Medical Necessity Criteria

Coding

Provider Actions & Billing Rules

Background, Definitions & FAQs

Medicare Determinations

Revision History