HCPCS G0108 Definition
Code G0108 is defined as, “diabetes outpatient self-management training services, individual, per 30 minutes.” This code is used to bill for diabetes education that is provided one-to-one, rather than as a group class.
Diabetes Self Management Training
Diabetes self management training (DSMT), also known as diabetes self management education and support (DSMES), is a service in which patients are educated on diabetes. Topics may include:
- Pathophysiology of diabetes
- Diabetes treatment options
- Coping strategies
- Physical activity
- Medications, including insulin
- Monitoring blood sugars
- Reducing risk of complications
- Problem solving
- Behavior change strategies
Billing Medicare for DSMT
Medicare requires a detailed referral from a physician or non-physician practitioner for this service.
Only providers that are a part of accredited programs can bill Medicare for this service. Accreditation can be through the American Diabetes Association (ADA) or the Association of Diabetes Care and Education Specialists (ADCES).
Getting a program accredited is a laborious, ongoing process that requires an application, significant fees, documentation and annual reporting.
What Providers Can Bill G0108?
Per the Centers for Medicare and Medicaid Services (CMS), the following provider types can bill for DSMT:
- Registered dietitians and nutrition professionals
- Physicians (MD or DO)
- Physician assistants
- Nurse practitioners
- Clinical nurse specialists
- Clinical psychologists
- Licensed clinical social workers
Healthcare providers such as pharmacists or registered nurses, cannot bill Medicare directly, but could be a part of the DSMT team that would then bill under the sponsor of the program. The sponsor could be an individual, such as an individual provider with one of the specialties listed above, or an entity such as a hospital, medical practice group or pharmacy.
Frequency Limit of G0108
Medicare covers 10 hours of DSMT for the initial benefit period, which must be completed within 12 months of the first encounter. However, they generally only allow 1 hour of this to be used for individual training, while the rest is to be done in a group setting. There are some exceptions to this rule, which include:
- There is no available group session within 2 months of the training being ordered
- The beneficiary has special needs that would inhibit effective participation in a group setting
- The physician ordered additional insulin training
After the initial benefit period, Medicare allows up to 2 hours of DSMT per year. This can be provided either individually, using HCPCS G0108, or as a group, using HCPCS G0109.
Medicare has a daily limit of 3 hours of individual DSMT and 6 hours of group DSMT.
Can You Round When Billing G0108?
G0108 is a time-based code with a unit of 30 minutes. CMS does not have specific guidance on rounding for this code, therefore, it is recommended not to round to the nearest unit.
Can G0108 Be Used When Billing for Group Classes?
No, procedure code G0108 cannot be used for billing group diabetes self management classes, as it is specifically for individual sessions. HCPCS code G0109 is to be used when billing group sessions of 2 individuals or more.
G0108 and G0109 Reimbursement
Medicare fee schedules are public information, which can be found using the CMS Search the Physician Schedule Look-Up Tool. If the sponsor of the program is a physician, 100% of the fee schedule will be paid out. If the sponsor is a non-physician, such as a registered dietitian, nurse practitioner or physician assistant, only 85% of the fee schedule will be paid.
For Medicare beneficiaries, DSMT is considered a preventive service, so there is no deductible, coinsurance or copay.
Billing DSMT vs MNT
The procedure code G0108 is for diabetes self-management training, while CPT codes 97802 and 97803 are for medical nutrition therapy (MNT). These are separate, but complimentary services with potential overlap. It is important to note that MNT can only be provided by registered dietitians or nutrition professionals.
Medicare will not pay for both DSMT and MNT provided on the same day.
Billing G0108 and G0109 can be challenging because Medicare has several requirements, including program accreditation as well as specific criteria that has to be met in order to provide DSMT on an individual basis. The fact that the time spent providing DSMT cannot be rounded is also a disadvantage of billing this benefit.
Providing and billing MNT could potentially be an easier way to furnish care to patients with diabetes that generally has a higher reimbursement rate as well.
DSMT vs MNT Reimbursement Examples
When comparing the reimbursement rate for G0108 and 97802/97803, the latter generally pays out similarly or higher. Here are a few examples using the 2024 Medicare national payment amounts for non-facilities:
An accredited program sponsored by a physician will get paid $53.37 per 30 minute unit of G0108 since they get 100% of the fee schedule, which is $106.74 per hour. If a dietitian is billing for MNT, only 85% of the fee schedule is paid out due to the provider type. Therefore, for an initial appointment using CPT code 97802, with each 15 minute unit paying out at $30.34 , the amount paid would be $121.36 per hour. However, if this is a follow up appointment, only $26.44 will be paid per unit, which is $105.76 per hour.
So in this example, MNT codes will pay out more compared to G0108 if it is an initial MNT appointment. If it is a follow up MNT appointment, the payment is almost the same when compared to G0108 ($105.76 versus $106.74).
If an accredited program is sponsored by a dietitian, they will get paid 85% of the fee schedule, which is $45.36 per unit of G0108. If a patient has a 45 minute appointment, only one unit of G0108 can be billed because it is recommended not to round. Therefore, the reimbursement amount would be $45.36. If the MNT codes were used, 3 units could be billed for, so either a total of $91.02 for an initial appointment, or $79.32 for a follow up appointment.
In this example, MNT is the clear winner for reimbursement, paying up to over twice the amount of DSMT. This is important to consider when deciding what provider types should be on your diabetes education team. Having a dietitian on staff can allow you to bill for MNT and get a better return on investment.
Billing Commercial Plans for G0108
Not all commercial plans seem to require providers to be a part of accredited programs to bill for DSMT. Commercial plans may also not require a referral or have a frequency limit. It is important to clarify this information before billing for this service. Unfortunately, this information is sometimes challenging to get.
There may or may not be some sort of patient responsibility such as a copay, when billing commercial plans for G0108.
Most payers reimburse less for G0108 compared to the MNT codes, when comparing time spent hour-for-hour. Remember that G0108 is a 30 minute unit while 97802 and 97803 are 15 minute units.
DSMT is a great benefit to those with diabetes. However, Medicare makes providers jump through many hoops to be able to deliver this service. For many organizations, the cost and effort of creating and maintaining an accredited program may not be worth the reimbursement rates of G0108 and G0109.
If a registered dietitian is available to provide services to patients with diabetes, it may make more sense to provide and bill for MNT instead.
Commercial plans may or may not follow Medicare guidelines when it comes to billing G0108. It is important to verify this information prior to billing for these services.