Diabetes Self-Management Education and Support

If a program meets the national standards, the CMS has authorized the ADCES to issue accreditation and ADA to issue recognition.² Though the terminology varies between organizations, either accreditation or recognition helps ensure that the DSMES services provided by an organization are high-quality and evidence-based.²

Many organizations seek accreditation or recognition for their DSMES programs for the following reasons: ^2,3

• The ability to bill for DSMES services through Medicare, some state Medicaid agencies, and many private insurers (Medicare and Louisiana Medicaid refer to DSMES as DSMT, or Diabetes Self-Management Training)
• To be able to access ADCES and ADA resources and support to better structure DSMES services
• To be able to market DSMES services provided as being high-quality and meeting national standards

Applying for Accreditation or Recognition

The initial application process for accreditation or recognition requires implementation and documentation for each of the required six National Standards. Aadditional details on each standard and what needs to be submitted for review can be found on the ADCES website. ADCES provides examples of National Standards for DSMES.⁴

The ADCES and ADA have differing requirements for each standard, please see this document for more information.⁵

• For accreditation through ADA Education Recognition Program (ERP), applicants must contact ERP at 888-232-0822 and choose option 1 or email ERP@diabetes.org.
• For accreditation through ADCES Diabetes Education Accreditation Program (DEAP), applicants can set up their DEAP account here.

Eligible Program Coordinators:

• Registered nurse (RN)
• Registered dietitian/nutritionist (RDN)
• Pharmacist with training and experience pertinent to DSMES
• Other healthcare professionals holding a Certified Diabetes Educator or Board Certified-Advanced Diabetes Manager (CDE or BC-ADM)

Eligible Facilities:

• Hospitals
• Independent healthcare clinics
• Pharmacies
• Rural health clinics
• Federally qualified health centers
• Patient-centered medical homes
• Home health agencies
• Skilled nursing homes
• Community-based organizations
• Community centers
• Faith-based organizations
• Area Agencies on Aging
• Durable medical equipment companies
• Assisted living facilities
• Worksites

Eligible participants:

• Must be newly diagnosed with diabetes (Type 1 or 2), gestational diabetes, pregnant with a history of diabetes, or never received diabetes education after being diagnosed.
• Must demonstrate poor glycemic control (A1C >7).
• Must have had an acute episode of severe hypoglycemia or hyperglycemia occurring in the past 12 months.
• Must have received a diagnosis of a complication, a diagnosis of a co-morbidity, or prescription for new equipment such as an insulin pump.

Eligible participants:

• Must be newly diagnosed with diabetes (Type 1 or 2), gestational diabetes, pregnant with a history of diabetes, or never received diabetes education after being diagnosed.
• Must demonstrate poor glycemic control (A1C >7).
• Must have had an acute episode of severe hypoglycemia or hyperglycemia occurring in the past 12 months.
• Must have received a diagnosis of a complication, a diagnosis of a co-morbidity, or prescription for new equipment such as an insulin pump.

For Medicare reimbursement, DSMES services cannot be provided in inpatient hospital settings nor End Stage Renal Disease (ESRD) facilities. A quality coordinator will be designated to ensure the implementation of the National Standards and oversee the DSMES program.

DSMES in Rural Health Centers (RHCs)

Louisiana Medicaid Coverage and Reimbursement

Louisiana Medicaid does not reimburse RHCs separately for DSMT/DSMES encounters. DSMT/DSMES services are considered part of the encounter rate, however, a DSMT/DSMES encounter on its own does not constitute a visit.

Medicare Coverage and Reimbursement

Medicare does not reimburse RHCs separately for DSMT/DSMES services. DSMT/DSMES services are considered included in the all-inclusive rate.

DSMES in Federally Qualified Health Centers (FQHCs)

Louisiana Medicaid Coverage and Reimbursement

Louisiana Medicaid does not reimburse FQHCs separately for DSMT/DSMES encounters. DSMT/DSMES services are considered part of the encounter rate, however, a DSMT/DSMES encounter on its own does not constitute a visit.

Medicare Coverage and Reimbursement

Under Medicare, FQHCs can receive separate payment for DSMT/DSMES services. However, under the PPS model, FQHCs do not qualify for separate payment when DSMT/DSMES services are billed on the same day as another qualifying visit. Additionally, the DSMT/DSMES services provided must be medically necessary and must be one-on-one, face-to-face encounters. FQHCs would use code G0466 or G0467 to bill for DSMT/DSMES services.

After an application to start a DSMES has been submitted:

• An initial application fee of $1,100 is paid for a 4-year period
• There is a $100 fee per site location
• Review of the application can take up to 30 days
• Applications requiring additional information or corrections during review process may take longer than 30 days to complete review
• The program coordinator will be notified via email when an application has been approved or returned for additional documentation

DSMES programs are typically delivered in-person, either in small groups or in a classroom-based setting. Technological advancements and evolving need has led some organizations, particularly those in rural locations, to turn to telehealth to deliver DSMES services to community members living with diabetes. The COVID-19 Public Health Emergency (PHE), for instance, has further demonstrated the need and benefits to offering health services like DSMES via telehealth, particularly to vulnerable and underserved populations.

DSMES services may take place in the following settings:²

• Telehealth
• Rural health clinics (RHCs)
• Federally qualified health centers (FQHCs)
• Provider practices
• Hospital outpatient departments
• Independent clinics
• Pharmacies
• Patient-centered medical homes
• Public health departments
• Safety net organizations
• Home health agencies
• Skilled nursing homes
• Community-based organizations
• Community centers
• Faith-based organizations
• YMCAs
• Area Agencies on Aging
• Durable medical equipment companies
• The home of the person with diabetes
• Assisted living facilities
• Worksites

Medicare offers coverage for DSMT/DSMES services when certain requirements are met, these include:

• The treating physician or treating qualified non-physician practitioner who is managing the beneficiary’s diabetic condition must certify that DSMT/DSMES services are needed
• DSMT/DSMES programs must be accredited or recognized by a CMS approved national accreditation organization, either ADA or ADCES
• DSMT/DSMES providers must be enrolled in Medicare

Medicare Part B covers 10 hours of initial training for a beneficiary who has been diagnosed with diabetes, and two hours per year for annual follow-up training. CMS outlines specific requirements for initial training and follow-up training.

Initial training is only available to patients who have never had DSMT/DSMES training before. Additionally, the training must be furnished over no more than 10 hours within a continuous 12-month period. Training is usually furnished in a group setting, with the exception of one hour of individual training, typically insulin training.

CMS only offers coverage for up to two hours of follow-up training per beneficiary per year. Follow-up training is typically delivered in a group setting consisting of around two to 20 participants. CMS does not require all participants in group follow-up training to be Medicare beneficiaries. Follow-up training must be delivered in increments of no less than 30 minutes. Additionally, the physician (or qualified non-physician practitioner) treating the beneficiary must document in the beneficiary’s medical record that the beneficiary has diabetes.

Louisiana Medicaid provides coverage for DSMT/DSMES services for eligible Medicaid recipients who:

1. Have a written order from their primary care provider, and
2. Have been diagnosed with Type 1, Type 2 or gestational diabetes.

Louisiana Medicaid covers a maximum of 10 hours of initial training within a continuous 12-month period. Initial training includes one hour of individual training and nine hours of group training. Louisiana Medicaid also offer coverage for up to two hours of individual follow-up training for each subsequent year. Louisiana Medicaid outlines specific requirements for initial and follow-up training.

The 10 hours of initial training may be provided in any combination of 30 minute increments over a continuous 12-month period. Louisiana Medicaid does not reimburse for initial training sessions that last less than 30 minutes. Each group training session will contain between two to 20 recipients. Louisiana Medicaid recipients must not have previously received initial or follow-up DSMT/DSMES training.

After receiving initial training, Louisiana Medicaid recipients are eligible to receive a maximum of two hours of follow-up training each subsequent year. The follow-up training must also be ordered by their primary care provider. If a Louisiana Medicaid recipient does not use all 10 hours of initial training within the first calendar year, then the recipient has 12 months to complete the initial training prior to follow-up training.

DSMES is often delivered in a group format (2-20 participants) within a continuous 12-month period. The sessions are at least 30 minutes in length. DSMES may be delivered one-on-one if certain conditions determined by the Centers for Medicare and Medicaid Services (CMS) exist, these include:⁶

1. No DSMES group sessions scheduled within two months of referral date
2. Provider orders “additional insulin training” on DSMES referral
3. Provider documents on referral that the individual has special needs or limitations identified by the provider that will limit effective participation in a group session (ex: COVID-19 risk)
4. Provider documents the need for individual training in the referral

If programs have the capability, group DSMES sessions may also be delivered via telehealth in some instances.

Medicare covers up to 10 hours of DSMES initial training (over the 12-month period). Following completion of the full 10 hours of initial training, Medicare also covers follow-up training up to 2 hours of individual or group training per beneficiary year.⁶

Curriculum

DSMES sessions may cover a variety of topics that are personalized to the needs of the participant. DSMES providers work with participants to create a plan of care that is customizable to their specific lifestyle, culture, beliefs, and environment.⁷

Some examples of DSMES session topics may include:⁷

• Stress management
• Eating with diabetes
• Benefits of physical activity
• Importance of medication taking

An accredited or recognized DSMES program is required to develop an appropriate DSMES curriculum that meets Standard 4 of the National Standards (See: DSMES Recognition and Accreditation, page 8). The American Diabetes Association (ADA) and Association for Diabetes Care & Education Specialists (ADCES) can provide additional guidance on curriculums that meet Standard 4. Additionally, a DSMES program may also choose to use an existing program curriculum that meets Standard 4 requirements, such as:⁸

• Live in Control
• Healthy Interactions Conversation Maps
• ¡Sí, Yo Puedo Controlar Mi Diabetes! (¡Sí, Yo Puedo!)
• ADCES Diabetes Care and Education Curriculum (Based on the ADCES7 Self-Care Behaviors)

In order for Medicare beneficiaries to receive coverage for DSMT/DSMES services, they must receive a written referral from their treating physician or qualified non-physician practitioner (such as a physician assistant, nurse practitioner, or advanced practice nurse). Additionally, a participant must also have full documentation of a diagnosis of Type 1, Type 2, or gestational diabetes that fall under the following criteria:

• Fasting Blood Glucose: ≥126 mg/dL on two separate occasions
• 2-Hour Post-Glucose Challenge: ≥200 mg/dL on two separate occasions
• Random Glucose Test: ≥200 mg/dL with symptoms of uncontrolled diabetes

Maintaining a well-structured referral process is important for building a strong and sustainable DSMES service. It is important to develop an internal process for soliciting, receiving, and processing referrals. The Centers for Disease Control and Prevention (CDC) recommends taking a team-based approach to referral and treatment and clearly identifying each team member’s roles and responsibilities within that workflow.² For example, one team member may be responsible for following up with referring providers.

When to Refer

The American Diabetes Association (ADA) and the Association of Diabetes Care & Education Specialists (ADCES) identified four key times to refer people with diabetes to DSMES services:²

1. At diagnosis
2. During an annual assessment or when a patient is not meeting treatment targets (ex: unexplained or frequent hypo- or hyperglycemia)
3. When complicating factors develop (ex: change in emotional well-being)
4. When transitions in life and care occur (ex: age-related changes)

There are different documentation requirements for referrals. The documentation requirements may be different based on place of service (RHC, FQHC, etc.). Please see this document that highlights Medicare coverage guidelines.²

Here is an example of a sample referral form for DSMES services.