Abstract
Reimbursement for diabetes self-management training (DSMT), which is the Medicare benefit for diabetes self-management education and support (DSMES), can be a challenge in recognized and accredited programs, particularly in a Federally Qualified Heath Center (FQHC) setting. Medicare only reimburses one-on-one DSMES (G0108) in this setting, and these visits cannot be billed on the same day as a medical visit. FQHCs also utilize additional G codes for each visit that specify if the participant is a new (G0466) or an established patient (G0467).
Amy Carter, MA, RDN, LD, CDCES, is the Diabetes Education Accreditation Program quality coordinator for Eskenazi Health Center (EHC) Diabetes Education Program. The program serves close to 250 adults each year in Indianapolis, Indiana, primarily individuals with type 2 diabetes. The participant population includes 63% Black/African American individuals, 24% Hispanic, and 12% White.
The DSMES team is composed of pharmacists, registered dietitian nutritionists, and certified diabetes care and education specialists. At present, the program does not have any FTEs specifically dedicated to only DSMES. The team also provides a variety of other services, including medical nutrition therapy, lifestyle medicine services, and clinical pharmacy services.
Amy and her team have successfully been reimbursed for their one-on-one DSMT services. She shares her experience, insights, and advice.
Why Was Billing and Reimbursement a Challenge for Your FQHC?
The EHC Diabetes Education Program became accredited in 2014, and for the majority of that time, it operated primarily as a group-based DSMES model. That worked well for patient engagement and outcomes, but it didn’t align well with billing rules for FQHCs since Medicare only reimburses one-on-one DSMES in this setting. Providers who engaged with patients alongside our groups were billing for their own clinical visits, but DSMES itself wasn’t being billed individually—and that meant we were missing opportunities for reimbursement.
With the increasing costs in health care and funding shifting away from our organization, making the program sustainable became an increasing need. We decided to begin the journey to successful reimbursement of DSMES services in 2024.
Who Were the Key Stakeholders Involved in the Process?
The initiative required collaboration from several teams:
What Did the Process Look Like?
It took us time to fully understand how DSMES billing fits within the unique FQHC framework and what changes we needed to make to align everything. I initially asked the chief operating officer for permission to pursue the revenue opportunities. Then, over several months, the nutrition leadership team and I met with stakeholders across compliance, billing, IT, and leadership.
The longest piece was making sure the EHR was built correctly to get the right structure in place, the right codes available, and the workflow clear for our teams. Due to other system and resource constraints, this delayed progress around 6 months.
The program then worked to enroll DSMES team members as providers where applicable with payers and completed staff training, followed by practice and chart audits to make sure everyone felt confident and remained compliant. Ultimately, from start to finish, it took almost a year to receive necessary approvals, build, train staff, and implement. It wasn’t quick, but each step built momentum.
What Were Some Key Learnings Along the Way?
One of the biggest surprises was how much confusion existed around what could and could not be reimbursed by each payer. Many internal partners had understandable hesitation, and it took time to work through a lot of misconceptions. Additionally, EHR builds almost always take longer than expected, especially when the goal is to make documentation simple, consistent, and compliant. Partnering closely with compliance and billing ensured the rules were followed but slowed progress considerably.
Knowing What You Know Now, How Would You Have Changed Your Process From the Start?
Beginning the EHR build much earlier and engaging the compliance team into the process from day 1. Their insights were essential, and having them engaged sooner would likely have facilitated a more streamlined process.
Creating a practical training approach for staff that included decision trees, charts, and real-life examples to help clarify when DSMES should be billed and when medical nutrition therapy (MNT) is more appropriate. Those nuances matter when the registered dietitians on the DSMES team previously only billed for MNT for people with diabetes.
What Advice Do You Have for FQHCs That Are Struggling to Get Reimbursed?
Use every resource you can get your hands on. The ADCES reimbursement team was incredibly helpful for us, and having outside experts to guide the process saved a lot of time and rework. Throughout our journey, ADCES supported the program with development of materials to understand sometimes complicated billing structures and needs.
Also, don’t underestimate the value of strong relationships with your compliance, billing, and IT teams. They’re essential partners in creating workflows that actually work in the real world.
Are There Any Learnings That Can Be Applied to All Site Settings, Not Just FQHCs?
No matter the setting, having a clear, thoughtfully designed EHR workflow is important. This ensures staff can easily document and track all needs. Credentialing and billing compliance are universal needs, too.
And across the board, investing in staff education—especially around the differences between MNT and DSMES—helps prevent confusion and supports consistent, compliant billing. ■