CurrentJefferson Health PlansPolicy RB.029.C

Diabetes Prevention Program (DPP) Reimbursement

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Reimbursement for CDC-recognized Diabetes Prevention Program participation, including member eligibility, program requirements, provider enrollment, billing codes, virtual-session modifiers, and Medicare payment rules across Jefferson Health Plans lines of business.

Policy Summary

PayerJefferson Health Plans

PolicyDiabetes Prevention Program (DPP) Reimbursement

Policy CodePolicy RB.029.C

Change TypeBilling code and provider enrollment updates

Effective DateNot specified

Last ReviewJan 30, 2025

Next Review DateNot specified

Key ActionVerify member eligibility and document qualifying prediabetes risk before enrollment.

SourceLink

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CurrentJefferson Health PlansPolicy RB.029.C

Diabetes Prevention Program (DPP) Reimbursement

Customize your policy alerts

Sign up for partners_insurance_company_dba_jefferson_health_plans Policy RB.029.C alerts

Get alerted when Policy RB.029.C changes without checking for updates manually.

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Policy Summary

PayerJefferson Health Plans

PolicyDiabetes Prevention Program (DPP) Reimbursement

Policy CodePolicy RB.029.C

Change TypeBilling code and provider enrollment updates

Effective DateNot specified

Last ReviewJan 30, 2025

Next Review DateNot specified

Key ActionVerify member eligibility and document qualifying prediabetes risk before enrollment.

SourceLink

POLICY UPDATE CHANGES

The current revision added Diabetes Prevention Program billing codes and related code descriptions.

The policy guidelines were updated with provider enrollment requirements for Medicaid and Medicare Diabetes Prevention Programs.

18+minimum member age

>25 BMIoverweight threshold

25one-hour sessions

5.7-6.4%prediabetes A1C range

58%cited risk reduction

Eligibility and Program Requirements

Member reimbursement eligibility

Participation in the Diabetes Prevention Program is eligible for reimbursement when all baseline member criteria and at least one qualifying risk criterion are met.

ALL of the following

ALL of the following
- Member is at least 18 years old.
- Member has a BMI greater than 25, or greater than 23 if Asian.
- Member has no previous diagnosis of type 1 or type 2 diabetes.
- Female member is not pregnant at the time of enrollment.
ONE of
- Member received a high-risk result after completing the CDC Prediabetes Risk Test.
- Within the past year, member had a hemoglobin A1C of 5.7%-6.4%.
- Within the past year, member had a fasting plasma glucose level of 100-125 mg/dL.
- Within the past year, member had a two-hour plasma glucose level of 140-199 mg/dL after a 75 g glucose load.
- Member was previously diagnosed with gestational diabetes.

Program and provider requirements

The participating program must be recognized by the CDC Diabetes Prevention Recognition Program, and provider enrollment requirements vary by line of business.

ALL of the following

Program is recognized by the CDC in its registry of approved programs, the Diabetes Prevention Recognition Program (DPRP).
Applicable provider requirement
- For Medicaid reimbursement, provider is enrolled with specialty code 223.
- For Medicare reimbursement, provider is enrolled with CMS and included in the Medicare Diabetes Prevention Program listing.

Program duration and reimbursement rules

The program is limited to one year and 25 one-hour sessions, and the applicable virtual-session and Medicare billing rules must be followed.

ALL of the following

DPP is limited to one year and 25 one-hour sessions.
Append modifier VM to any G-code provided as a virtual session.
For Medicare members only, claims reported with a diabetic diagnosis code, excluding gestational diabetes, or an End Stage Renal Disease diagnosis code will deny as not a covered benefit.

Billing Codes and Thresholds

Virtual-session modifierModifier

VM	Virtual Modifier; append to any G-code provided as a virtual session.

Diabetes Prevention Program and MDPP servicesHCPCSCovered

G9873	First MDPP core session attended during months 1 through 6.
G9874	Four total MDPP core sessions attended during months 1 through 6.
G9875	Nine total MDPP core sessions attended during months 1 through 6.
G9876	Two core maintenance sessions attended during months 7 through 9 when the beneficiary did not achieve at least 5% weight loss.
G9877	Two core maintenance sessions attended during months 10 through 12 when the beneficiary did not achieve at least 5% weight loss.
G9878	Two core maintenance sessions attended during months 7 through 9 when the beneficiary achieved at least 5% weight loss.
G9879	Two core maintenance sessions attended during months 10 through 12 when the beneficiary achieved at least 5% weight loss.
G9880	One-time payment when the beneficiary first achieves at least 5% weight loss from baseline during months 1 through 12.
G9881	One-time payment when the beneficiary first achieves at least 9% weight loss from baseline during months 1 through 24.
G9882	Two ongoing maintenance sessions attended during months 13 through 15 while maintaining at least 5% weight loss.

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Member eligibility

Minimum age18 years

Diabetes historyNo previous diagnosis of type 1 or type 2 diabetes

Pregnancy statusFemale member is not pregnant at enrollment

Overweight BMI

Standard BMI thresholdGreater than 25

Asian member BMI thresholdGreater than 23 if Asian

Additional eligibility requirement

Provider and Billing Checklist

Documentation Required

Confirm member eligibility

Verify that the member is at least 18 years old, meets the applicable overweight BMI threshold, has no previous diagnosis of type 1 or type 2 diabetes, and, if female, is not pregnant at enrollment.

>25 BMI; >23 if Asian

Documentation Required

Document qualifying prediabetes risk

Document at least one qualifying prediabetes-risk criterion: a high-risk result on the CDC Prediabetes Risk Test, a prediabetes-range blood test within the past year, or a prior diagnosis of gestational diabetes.

Hemoglobin A1C: 5.7%-6.4%.
Fasting plasma glucose: 100-125 mg/dL.
Two-hour plasma glucose after a 75 g glucose load: 140-199 mg/dL.

Policy Summary

PayerJefferson Health Plans

PolicyDiabetes Prevention Program (DPP) Reimbursement

Policy CodePolicy RB.029.C

Change TypeBilling code and provider enrollment updates

Effective DateNot specified

Last ReviewJan 30, 2025

Next Review DateNot specified

Key ActionVerify member eligibility and document qualifying prediabetes risk before enrollment.

SourceLink

On This Page

Member has no previous diagnosis of type 1 or type 2 diabetes

Prediabetes laboratory thresholds

TestHemoglobin A1C

Prediabetes range5.7%-6.4%

Required timingWithin the past year

Prediabetes laboratory thresholds

TestFasting plasma glucose

Prediabetes range100-125 mg/dL

Required timingWithin the past year

Prediabetes laboratory thresholds

TestTwo-hour plasma glucose

Prediabetes range140-199 mg/dL

Glucose loadAfter a 75 g glucose load

Program duration

Program durationOne year

Total sessions25 one-hour sessions

Session lengthOne hour per session

MDPP weight-loss milestones

Five-percent milestoneAt least 5% weight loss from baseline

Five-percent service periodMonths 1-12 of the MDPP services period

Nine-percent milestoneAt least 9% weight loss from baseline

Nine-percent service periodMonths 1-24 of the MDPP services period

Documentation Required

Screen and accept participants

Screen participants for prediabetes before acceptance, confirm that they meet the eligibility criteria, and assess whether they are motivated to complete the program and make the necessary lifestyle changes. Acceptance is at the sole discretion of the applicable DPP provider.

Billing Rule

Use a CDC-recognized program

Provide a Diabetes Prevention Program recognized by the CDC in its registry of approved programs, known as the Diabetes Prevention Recognition Program (DPRP).

Billing Rule

Meet Medicaid provider enrollment requirement

For Medicaid reimbursement, the provider must be enrolled with specialty code 223.

Billing Rule

Meet Medicare provider enrollment requirement

For Medicare reimbursement, the provider must be enrolled with CMS and included in the Medicare Diabetes Prevention Program supplier listing.

Billing Rule

Apply virtual-session modifier

Append modifier VM to any G-code that is provided as a virtual session.

Modifier: VM

Denial Risk

Avoid Medicare denial diagnoses

For Medicare members only, claims reported with a diabetic diagnosis code, excluding gestational diabetes, or an End Stage Renal Disease diagnosis code will deny as “not a covered benefit.”

Billing Rule

Apply lifetime code limit

The listed MDPP codes are limited to once per lifetime per member.

G9873, G9874, G9875, G9876, G9877, G9878, G9879, G9880
G9881, G9882, G9883, G9884, G9886, G9887, G9888, G9890