As we grow and develop our DPP’s, it is so reassuring to know that reimbursement is available. So where do you begin?
First, apply for CDC Recognition. The process is nicely laid out in the DPRP Standards. Why is this so important? So many reasons…but for the purpose of reimbursement, insurance companies are much more likely to reimburse if your DPP is CDC Recognized. And did you know, depending on the insurance company, reimbursement may be available in Full, Preliminary, or Pending status.
According to the AMA CPT Guidance-National DPP Lifestyle Change Program….. (open link to read entire article)
What are CPT Codes?
National DPP lifestyle change program-specific CPT codes CPT®, which stands for Current Procedural Terminology, is the code set used to describe procedures and services performed by physicians and other health care professionals or entities. CPT® is a registered trademark of the American Medical Association. A CPT code is a billing code used for clinical procedures that are consistent with contemporary medical practice. Currently, there are two CPT Category III tracking codes specific to the Centers for Disease Control and Prevention’s (CDC) National DPP lifestyle change program that more accurately identify the non- clinical services performed by CDC-recognized National DPP lifestyle change program providers. These codes are:
0403T-for in person programs
0488T-for on line/virtual programs
The codes are classified as Category III codes, a grouping of temporary codes for new or emerging services. These codes may be converted to Category I in the future. Category I are official billing codes for procedures that are consistent with contemporary medical practice. Please note, according the the NDPP Coverage Tool Kit-some agencies may not be able to reimburse for these Category III codes because of their temporary status. Please review the NDPP Coverage Tool Kit to learn more!
The current NDPP Category III CPT codes may be reimbursable when a price is determined by relevant stakeholders (such as an insurance carrier that would be receiving and paying claims and any of the NDPP providers in the CDC DPRP Registry who would be submitting a claim and accepting reimbursement).
Who can/should use these CPT codes?
The codes may be used by National DPP lifestyle change program providers that are CDC-recognized (aka “full recognition”) or have preliminary or pending recognition status. **Most likely, an insurance provider will require verification of your recognition status!
What steps should a DPP take to begin this process? Make sure….
• Systems are in place (processes, people, technology) to be able to submit claims to a payer
• National provider identifier (NPI) number applied for and assigned
• Payer source (e.g., private insurance or Medicaid) that has agreed to pay for the program
But what if I find out no reimbursement is available?
Even if no reimbursement is available, it is still important for CDC-recognized organizations to submit a claim when possible for all insured individuals (even those whose insurance provider is not yet covering the program) participating in the program. Therefore, in order to bill a particular insurer, National DPP lifestyle change program providers may need to collect insurance information from all of their insured participants.
Do you have to be under the supervision of a licensed provider to bill using CPT code 0403T or 0488T?
NO… CDC-recognized organizations that deliver the type 2 diabetes prevention program are the entities responsible for billing (as opposed to the individual lifestyle coaches leading the classes). These coaches include both lay health workers and licensed health care professionals who are trained to deliver the DPP.
What is the reimbursement rate?
CPT codes are procedure codes but do not determine or guarantee reimbursement. Reimbursement rate is set between the payer and the delivery organization (if not set by CMS) and, therefore, needs to be negotiated between these stakeholders. The CPT code then becomes a method to trigger reimbursement, as well as to track and report services rendered. This CPT code is a Category III tracking code. It can be reimbursable if a CDC- recognized organization has negotiated a fee with a payer.
Remember, MDPP, uses it’s own unique coding system. You can find this information on the State of Wellness Resources Page>MDPP category.
Credit: AMA/Prevent type 2 diabetes; CPT Code Guidance National DPP lifestyle change program;
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