Rule 5160-8-53 | Diabetes prevention and self-management training.
(A) Definitions. For the purposes of this rule, the following definitions apply:
(1) "Diabetes self-management training" (DSMT) is the education and instruction of an individual with diabetes by a qualified provider for the purpose of providing the individual with necessary skills and knowledge to participate in the management of the individual's diabetes, including the self-administration of injectable drugs.
(2) "National Diabetes Prevention Program" (NDPP) is an evidence-based, educational and support program administered by the centers for disease control and prevention (CDC) designed to assist at-risk individuals from developing type 2 diabetes.
(B) DSMT.
(1) Providers.
(a) Rendering providers. The following providers may render or supervise a DSMT service:
(i) A physician;
(ii) A physician assistant;
(iii) An advanced practice registered nurse;
(iv) A registered nurse;
(v) A registered dietitian nutritionist; or
(vi) A pharmacist.
(b) Billing ("pay-to") providers. The following providers may receive medicaid payment for submitting a claim for a DSMT service on behalf of a rendering provider:
(i) A physician;
(ii) A physician assistant;
(iii) An advanced practice registered nurse;
(iv) A licensed or registered dietitian;
(v) A pharmacist;
(vi) A professional medical group;
(vii) A federally qualified health center;
(viii) A rural health clinic;
(ix) An ambulatory health care clinic; or
(x) A hospital.
(2) Coverage.
(a) Payment for diabetes self-management training can be made when the following criteria are met:
(i) The individual has a current diagnosis of diabetes.
(ii) The individual has not previously received diabetes self-management training.
(iii) Training is provided in a setting other than an inpatient hospital or an emergency department.
(b) Payment may be made, with prior authorization in accordance with rule 5160-1-31 of the Administrative Code, for follow-up sessions not to exceed a total of two hours of individual training or group training in any combination.
(C) NDPP.
(1) Providers.
(a) Rendering providers. The following providers may render or supervise an NDPP service:
(i) A physician;
(ii) A physician assistant;
(iii) An advanced practice registered nurse;
(b) Billing ("pay-to") providers. The following providers may receive medicaid payment for submitting a claim for an NDPP service on behalf of a rendering provider:
(i) A physician;
(ii) A physician assistant;
(iii) An advanced practice registered nurse;
(iv) A professional medical group;
(v) A federally qualified health center;
(vi) A rural health clinic; or
(vii) An ambulatory health care clinic;
(2) Coverage.
(a) Payment for an NDPP service can be made when all of the following criteria are met:
(i) The individual is eighteen years or older;
(ii) The individual is overweight;
(iii) The individual is not currently pregnant; and
(iv) The individual does not have a diagnosis of type 1 or type 2 diabetes.
(v) At least one of the following criteria is met:
(a) The individual has been diagnosed with prediabetes;
(b) The individual has a history of gestational diabetes; or
(c) The individual has had a high-risk result on a prediabetes test.
(D) Claim payment.
(1) No payment will be made for a DSMT or NDPP service provided on the same date of service as medical nutrition therapy.
(2) Payment for a covered service performed in a hospital is made in accordance with Chapter 5160-2 of the Administrative Code.
(3) Payment for a covered service rendered by a federally qualified health center (FQHC) or rural health clinic (RHC) is made in accordance with Chapter 5160-28 of the Administrative Code.
(4) Payment for a covered service rendered in any other setting is the lesser of the submitted charge or the amount shown in appendix DD to rule 5160-1-60 of the Administrative Code.
Last updated January 3, 2022 at 9:49 AM
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