Offering DSMES Services through Telehealth
Diabetes is a lifelong condition that requires daily self-management and complex care regimens that may be difficult for people to navigate without support.1 Diabetes Self-Management and Support (DSMES) is an evidence-based intervention that provides people with diabetes with the knowledge, skills, and support needed to better manage and navigate daily life with a chronic condition.
Though typically in person, DSMES delivered via telehealth allow participants to access services without having to travel long distances and may even be able to attend sessions from the comfort of their homes.
DSMES delivered via telehealth is expected to uphold the same quality standards as in-person DSMES. Telehealth services follow the same curriculum as in-person DSMES, and participants are required to complete session items, such as participant assessments, just as they would during an in-person program. Participants also have access to the same DSMES resources and tools that they would have access to during an in-person program.
Starting DSMES Services at Your Facility
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Benefits of DSMES via Telehealth
Delivering DSMES via telehealth offers many benefits to both providers and participants. On a high-level, DSMES via telehealth:
- Enables providers to expand their reach with greater efficiency and in less time
- Promotes health equity by providing DSMES services to underserved populations
- Decreases barriers to participation related to transportation or provider shortages
- Is sustainable and, usually, reimbursable
Who Can Provide DSMES Telehealth Services?
For Medicare reimbursement, DSMES telehealth services must be provided by a qualified DSMES provider who is also one of the following provider types:
- Nurse Practitioners
- Physician Assistants
- Nurse Midwives
- Certified Nurse Specialists
- Certified Registered Nurse Anesthetists
- Clinical Phycologists
- Clinical Social Workers
- Registered Dieticians or Nutrition Professionals
- Registered Nurses
Louisiana Medicaid does not limit the providers that can provide services via telehealth. Each licensing board (LSBME, Board of Nursing, etc.) can limit their provider’s ability to deliver services via telehealth.
During the COVID-19 public health emergency, the Centers for Medicare and Medicaid Services (CMS) released updated guidance that allowed accredited and recognized DSMES programs (that are eligible to bill Medicare Part B for DSMES services) to provide and bill for DSMES services delivered via telehealth during the public health emergency.
Services provided via telehealth must be delivered at the same standard of care as services delivered in-person, as determined by the provider. Therefore (at a minimum), DSMES via telehealth providers will need to have access to technology that supports both real-time audio and video capabilities (such as a computer, smartphone, or tablet). DSMES participants will also need to have access to a smartphone, computer, or tablet with functional internet that supports real-time audio and video capabilities.
There are also numerous telehealth platform vendors that can help facilitate telehealth services. Your selected telemedicine platform should be HIPAA-compliant.
In response to the COVID-19 public health emergency, the Centers for Medicare and Medicaid Services provided updated guidance that allowed DSMES via telehealth services to be provided via audio-only in instances where real-time video and audio capabilities are not possible. 3,4
Start a Telemedicine Program
By offering telehealth services at your facility, you can make DSMES and other important services more accessible to your patients.
DSMES Telehealth Billing
For billing purposes, make sure that services are provided by a healthcare provider who is qualified to bill the relevant payor for services provided via telehealth.
Healthcare providers must utilize the below billing codes:
- The same code as in-person visits would be utilized, G0108 for 1:1 and G0109 for group, with the place of service code either 02 (other than home) or 10 (home), based on the beneficiary’s location at the time of service, for both Medicare and Medicaid billing.
- For Medicare, the “-GT” modifier for Telehealth Distant should be appended to the relevant codes if billing under Critical Access Hospital (CAH) Option Payment Method II.
- For Medicaid, the “-95” modifier should also be appended to all relevant CPT codes to indicate that the service was provided via telemedicine. Providers must indicate the appropriate place of service, either 02 (other than home) or 10 (home), based on the beneficiary’s location at the time of service and must append modifier – 95. RHCs should also include the modifier on the header line.
Providers will need to verify with their individual Managed Care Organizations (MCO) to determine if this service is covered via telehealth delivery. DSMT telehealth reimbursement remains the same as during the PHE for DSMT in all practice settings through at least the end of 2023. ADCES Accredited and ADA Recognized programs were added to the list of approved telehealth providers via the 1135 Waivers. H.R.2471 – Consolidated Appropriations Act, 2022 extending the public health emergency flexibilities that have allowed DSMES programs to furnish services via telehealth and receive reimbursement for DSMT through the end of 2024.
For RHC or FQHC billing information, please see DSMES in Rural Communities.
Reimbursement for Audio-only DSMES
Under normal circumstances, neither Medicare nor Medicaid reimburse DSMT/DSMES (G0108 or G0109) provided via audio-only communication.
Due to the COVID-19 public health emergency, Medicare DSMT/DSMES codes (G0108 and G0109) are now included on the list of telehealth services that can be provided via audio-only technology during the COVID-19 public health emergency.
When billing Medicaid, for the duration of the COVID-19 public health emergency, in cases where an interactive audio or video system (ex: telephone) without the requirement of video may be employed, unless noted otherwise. For use of an audio-only system, the same standard of care must be met and the need and rationale for employing an audio-only system must be documented in the clinical record. Providers will code or bill the same as a telemedicine (real-time audio/video) visit.
DSMES in Rural Communities
Rural communities throughout the United States are disproportionately impacted by diabetes. Diabetes prevalence is 17% higher in rural areas compared to their urban counterparts, and most nonmetropolitan counties do not have a DSMES program.3
Telehealth technology may help more rural residents living with diabetes gain access to DSMES programs, particularly in communities without an in-person DSMES program. Many rural residents also cite a lack of reliable transportation as a barrier to their participation in health programs, like DSMES.3 Telehealth can help ease participant barriers to access by eliminating the need to travel long distances to attend an in-person DSMES program.
Rural health centers (RHCs) and federally qualified health centers (FQHCs) have specific guidelines to follow to be eligible for DSMES reimbursement through Medicaid/Medicare.
DSMES in Rural Health Centers (RHCs)
DSMES via Telehealth: Distant Site
Under normal circumstances, Medicare does not allow RHCs to serve as telehealth distant site providers.
Louisiana Medicaid allows RHCs to serve as telehealth distant site providers, however, Louisiana Medicaid does not reimburse RHCs separately for DSMES services.
During the COVID-19 public health emergency, Medicare does allow RHCs to provide distant site services. Qualifying telehealth visits are billed with HCPCS code G2025.
DSMES via Telehealth: Originating Site
Medicare allows RHCs to serve as originating sites for telehealth visits and receive an originating site fee. Originating sites can bill utilizing HCPCS code Q3014 (originating site facility fee) and utilize the appropriate place of service, either 02 (other than home) or 10 (home), based on the beneficiary’s location at the time of service to indicate that the service was provided via telemedicine.
Louisiana Medicaid allows RHCs to serve as an originating site for telehealth services, but Louisiana Medicaid does not pay originating site fees.
Under normal circumstances, providers must be in a rural area to serve as the originating site for Medicare, however, during the COVID-19 public health emergency, this restriction is waived.
DSMES in Federally Qualified Health Centers (FQHCs)
DSMES via Telehealth: Distant Site
Under normal circumstances, Medicare does not allow FQHCs to serve as telehealth distant site providers.
During the COVID-19 public health emergency, Medicare does allow FQHCs to provide distant site services. Qualifying telehealth visits are billed with HCPCS code G2025.
DSMES via Telehealth: Originating Site
Medicare allows FQHCs to serve as originating sites for telehealth visits and receive an originating site fee. Originating sites can bill utilizing HCPCS code Q3014 (originating site facility fee). Providers must indicate the appropriate place of service, either 02 (other than home) or 10 (home), based on the beneficiary’s location at the time of service and must append modifier -95.
Louisiana Medicaid allows FQHCs to serve as an originating site for telehealth services, but Louisiana Medicaid does not pay originating site fees.
Under normal circumstances, providers must be in a rural area to serve as an originating site for Medicare, however, during the COVID-19 public health emergency, this restriction is waived.
DSMES via Telehealth Project
DSMES services are drastically underutilized throughout the state and country.3 DSMES underutilization is often the result of one or more barriers related to access and participation.3 In the case of rural and underserved areas, DSMES programs may be limited or completely non-existent. As a result of this service shortage, many people living with diabetes in underserved areas are often unable to access valuable DSMES programs that may improve their long-term health status.
Telehealth technology is one solution to improving access to DSMES programs in underserved areas. Therefore, Well-Ahead is exploring the feasibility, effectiveness, and replicability of implementing telehealth DSMES in FQHCs and RHCs. Through the DSMES via Telehealth Project, Well-Ahead Louisiana is partnering with health care systems throughout the state to expand the use of telehealth technology to deliver DSMES programs in underserved areas.
The DSMES via Telehealth Project allows patients at Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) to receive DSMES services at their primary care clinic, in a familiar environment close to home. The clinic maintains care of the patient and communicates regularly, with the diabetes educator to help support the patient in reaching their health goals.
The DSMES via Telehealth Project will focus its programmatic efforts to serve patients in the following parishes:
- Jefferson Davis
- Red River
- West Baton Rouge
DSMES providers participating in this project will need to meet the following deliverables:
- Work collaboratively with Well-Ahead to implement the program, including participating in collaboration and planning meetings with Well-Ahead staff and partner clinic staff to develop and execute the work plan for program implementation.
- Receive and maintain American Diabetes Association (ADA) recognition or American Association of Diabetes Care & Education Specialists (ADCES) accreditation.
- With support of Well-Ahead, identify and conduct outreach to potential clinic partners.
- Partner with one to five clinics to provide DSMES via telehealth to their patients. As part of these partnerships, providers shall, at a minimum:
- Work collaboratively with clinics to implement the program;
- Develop a referral process with the clinics and provide the appropriate referral forms or tools;
- Develop a scheduling process with the clinics and provide the appropriate forms or tools;
- Provide guidance and technical assistance as necessary to assist clinics in selecting telehealth equipment that can connect effectively with provider telehealth delivery platform;
- Provide any guidance or training necessary for clinic facilitators to assist in DSMES class sessions; and
- Ensure bi-directional referral process by providing feedback to referring clinics on patient progress/status.
- Provide telemedicine diabetes educators and course instructors whose responsibilities will include:
- Work collaboratively with clinics to ensure appropriate development and implementation of the referral and scheduling process;
- Deliver DSMES class sessions in accordance with ADA or ADCES guidelines;
- Ensure bi-directional referral process by providing follow-up communication to partner clinic staff;
- Complete survey or interview for Well-Ahead staff regarding program implementation experience for evaluation purposes.
- Support rigorous evaluation of the program as outlined in the Program Evaluation section below.
Well-Ahead can support DSMES providers with project implementation in the following ways:
- Provide technical assistance, guidance and financial support in obtaining ADA recognition or ADCES accreditation and certified diabetes educator (CDE) certification for the DSMES educator.
- Provide technical assistance and guidance regarding implementation, regulatory considerations and billing considerations of a DSMES via telehealth program.
- Provide financial support for staff time to implement the program and provide support to the clinics.
- Drawing on extensive experience working in rural areas and established relationships with rural health clinics, support and assist in identifying and establishing connections with potential clinic partners.
- Well-Ahead will also support partner clinics by:
- Providing technical assistance and guidance regarding implementation, regulatory considerations and billing considerations of serving as an originating site for DSMES telehealth;
- Providing funding to support staff time for education and project implementation as well as funding to purchase needed telehealth equipment.
The Well-Ahead Program Evaluator will use a repeated measure design to assess the effectiveness of DSMES telehealth. Surveys will be distributed to all partner sites delivering DSMES via telehealth and will measure knowledge, behavior and satisfaction. Results will be reported to the CDC. All participants will remain anonymous, and personal health information will be protected.
DSMES providers participating in this project will need to meet the following deliverables related to program evaluation:
- Distribute, de-identify, and submit patient feedback surveys to Well-Ahead Evaluator.
- Pre-Assessment (distributed at or before first class), Post-Assessment, (distributed at or after last class) and 3-Month Follow-Up Assessment (distributed three months following final class)
- Administer Well-Ahead Evaluation surveys (pre-test, post-test, three-month follow-up, or non-completion).
- Coordinate three-month follow-up assessments and referring provider progress reports with participant biomarkers (average blood glucose A1C, weight, blood pressure) with participants.
- Report de-identified patient data on Well-Ahead Evaluation measures, as defined in the Evaluation Plan, including (but not limited to) demographics, classes or sessions ordered by referring provider, attendance, A1C, body weight and blood pressure.
- Coordinate with Well-Ahead Evaluation staff to perform site visit(s), class session observation(s) and quality control checks as needed.
- Assure patient privacy and data protection by:
- Administering consent form to participants, securing forms under lock and key at program site.
- Coordinating with Well-Ahead Evaluation staff to assign participant identifiers to ensure confidentiality of clients.
- Adhering to agreed-upon protocols of Protected Health Information (PHI) and Health Insurance Portability and Accountability Act (HIPAA) standards, as outlined in the Evaluation Plan and the LDH Institutional Review Board (IRB) application.
- Securing assessments and surveys under lock and key at program site.
Well-Ahead Louisiana can support DSMES providers with meeting evaluation objectives in the following ways:
- Providing financial support to offset staff time to complete evaluation tasks.
- Providing guidance and tools to collect and report requested data.
- Distribute, de-identify, and submit patient feedback surveys to Well-Ahead Evaluator.
RHCs and FQHCs interested in participating in this project can complete the electronic Originating Site Clinic Application.