What Is Covered for DSMT and MNT? Is There a Cost to the Provider?
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Medicare beneficiaries are entitled to an initial 10-hour DSMT program that occurs within 1 year of initial referral (see Table 2). As mentioned, the DSMT program must address 10 content areas of diabetes care; Medicare requires that DSMT be provided in a group setting (2 or more persons). A provider who feels that group classes are inappropriate for a particular patient can make a referral for individual training.9 There are specific exemptions for group classes, including a loss of hearing or vision, a language barrier, or a psychological issue. The criteria for individual training have become less stringent, and referring providers can identify “special conditions that will hinder group learning.”10 However, for facilities and practitioners, it remains most cost-effective for diabetes education programs to provide DSMT in groups. After the initial 12-month period, the beneficiary is eligible to receive up to 2 hours of follow-up DSMT annually with another referral from the treating provider.
MNT must be provided by a registered dietitian. This benefit allows registered dietitians to apply for a Medicare Personal Identification Number (PIN) and to bill Medicare directly for their services. A signed and dated physician referral is required (nonphysician practitioners, such as nurse practitioners or physician assistants, cannot refer for MNT). The referral must include the beneficiary’s diagnosis related to the covered MNT benefit, indicate the medical necessity for MNT, and include the physician’s Unique Physician Identification Number (UPIN).11
The initial MNT benefit is 3 hours of service within the first calendar year and 2 hours for follow-up care within an episode of care (1 calendar year) (see Table 2). Additional hours in the calendar year are considered medically necessary and covered if the treating physician determines there is a change in medical condition, diagnosis, or treatment regimen that requires a change in MNT and orders additional hours during that episode of care. A physician referral is required for each episode.
Table 2. Covered DSMT Education Services9
Entity Covered* |
First Year |
Following Years |
Requirement |
DSMT |
10 hours |
2 hours |
Referrel needed |
MNT |
3 hours |
2 hours + |
Referral needed for each episode |
* Please note that these services are viewed as complementary. For reimbursement to occur, the services for DSMT and MNT cannot be performed on the same day.
