CPT g9873, g9874, G9875, G9880- G9891 - DIABETES PREVENTION

Medicare Diabetes Prevention Program: New Covered Service

Medicare Diabetes Prevention Program (MDPP)

"HCPCS G-Code"    Description    "VM Allowed* "    Payment 

CORE SESSIONS  
      
G9873     MDPP beneficiary attended the first MDPP core session.    No    $25
G9874     MDPP beneficiary attended a total of 4 MDPP core sessions.    Yes    $50
G9875     MDPP beneficiary attended a total of 9 MDPP core sessions.    Yes    $90

CORE MAINTENANCE SESSIONS  
      
G9876    MDPP beneficiary attended 2 MDPP core maintenance sessions in months 7-9.    Yes    $15

G9877    MDPP beneficiary attended 2 MDPP core maintenance sessions in months 10-12    Yes    $15

G9878    "MDPP beneficiary attended 2 MDPP core maintenance sessions in months 7-9, and
the 5% weight loss from his/her baseline weight. Use G9878 or G9876."    Yes    $60

G9879    "MDPP beneficiary attended 2 MDPP core maintenance sessions in months 10-12, and
achieved the 5% weight loss from his/her baseline weight. Use G9879 or G9877"    Yes    $60


ONGOING MAINTENANCE SESSIONS          

G9882    "MDPP beneficiary attended 2 MDPP ongoing maintenance sessions in months 13-15, and
achieved the 5% weight loss from his/her baseline weight during the interval."    Yes    $50

G9883    "MDPP beneficiary attended 2 MDPP ongoing maintenance sessions in months 16-18, and
achieved the 5% weight loss from his/her baseline weight during the interval."    Yes    $50

G9884    "MDPP beneficiary attended 2 MDPP ongoing maintenance sessions in months 19-21, and
achieved the 5% weight loss from his/her baseline weight during the interval."    Yes    $50

G9885    "MDPP beneficiary attended 2 MDPP ongoing maintenance sessions in months 22-24, and
achieved the 5% weight loss from his/her baseline weight during the interval."    Yes    $50

ADDITIONAL CODES          

G9880    "MDPP beneficiary achieved at least 5% weight loss from his/her baseline weight in months 1–
12. This is a one-time payment available when a beneficiary first achieves at least 5% weight
loss from baseline as measured by an in-person weight measurement at a core session or
core maintenance session.
"    No    $160

G9881    "MDPP beneficiary achieved at least 9% weight loss from his/her baseline weight in months 1–
24. This is a one-time payment available when a beneficiary first achieves at least 9% weight
loss from baseline as measured by an in-person weight measurement at a core session, core
maintenance session, or ongoing maintenance session"    No    $25

G9890    "Bridge Payment: A one-time payment for the first MDPP core session, core maintenance
session, or ongoing maintenance session furnished by an MDPP supplier to an MDPP
beneficiary during months 1–24. This occurs when a beneficiary has previously received
his/her first core session from a different MDPP supplier. A supplier may only receive one
bridge payment per MDPP beneficiary."    Yes    $25

G9891    "MDPP session reported as a line item on a claim for MDPP services. This is a non-payable
code for reporting services of sessions furnished to MDPP beneficiaries (i.e. core sessions 2-3,
5-8, 10-16, and maintenance sessions before achievement of a performance goal)"    Yes    $0




This reference guide provides a snapshot of the MDPP payment structure and corresponding Healthcare Common Procedure Coding System (HCPCS) G-codes. This guide only applies to services furnished to beneficiaries receiving Medicare Part B coverage via Medicare Fee-for-Service (FFS).

A Glance at What is Covered

The first year of MDPP core services includes six months of weekly core sessions followed by six months of monthly maintenance sessions; the second year is contingent upon beneficiary performance and consists of monthly maintenance sessions

Follows a CDC-approved curriculum

• No beneficiary copay
• No referral required
• Beneficiaries are eligible for MDPP once-per-lifetime
* The ongoing maintenance sessions are unique to the MDPP services and not required for CDC recognition.

Beneficiary Eligibility Criteria

Specific criteria determine Medicare beneficiary eligibility throughout the MDPP services period Beneficiary Eligibility Requirements to Start Services:


Medicare beneficiaries are eligible for MDPP services if they meet the following criteria:

• Enrolled in Original Medicare (Part B) or Medicare Advantage (Part C)

• Body Mass Index (BMI) of at least 25 (23 if self-identified as Asian) on the date of the first core session

• Meet 1 of 3 blood test requirements within the 12 months prior to attending the first core session:

1. A hemoglobin A1c test with a value between 5.7% and 6.4%, or
2. A fasting plasma glucose of 110-125 mg/dL, or
3. A 2-hour plasma glucose of 140-199 mg/dL (oral glucose tolerance test)

• No previous diagnosis of diabetes prior to the date of the first core session (with exception of gestational diabetes)

• Do not have End-Stage Renal Disease (ESRD)

• Have not previously received MDPP services

Important Details on Eligibility Criteria

See the Beneficiary Eligibility Fact Sheet for more information
• Beneficiaries are only required to provide results from one of the 3 blood tests by the first core session
• The test must be completed in the 12 months before the first core session
• Beneficiaries may work with their health care provider to obtain the blood tests
• CMS does not designate specific types or forms of documentation that should be used as evidence of blood test results
• Beneficiaries’ weight and height must be measured in-person at the first core session and should be used to calculate BMI




Important Details on Eligibility Criteria

History of Diabetes
•Beneficiaries may self-report their history of type 1 or 2 diabetes
• If a beneficiary develops diabetes while receiving MDPP services, they can continue with the program
• History of gestational diabetes, which develops during pregnancy, does not disqualify a beneficiary from receiving MDPP services

MDPP Services
 • Beneficiaries are only eligible for services once-per-lifetime
• Beneficiaries who participated in any DPP services before April 1, 2018, or before they had Medicare coverage, are still eligible because these are not considered MDPP services
• Up to 2 years of services are covered for eligible beneficiaries at no copay
• No provider referral required

Using MDPP HCPCS G-Codes

• HCPCS G-codes are used when submitting claims to bill Medicare for payment. MDPP HCPCS G-codes may be used only one time per eligible beneficiary (except for G9890 and G9891)

• The initial session (G9873) or bridge payment (G9890) claim must be submitted before any other claims will be paid

• MDPP suppliers should submit claims when a performance goal is met

• Use the non-payable G-code (G9891) to report attendance at sessions that are not associated with a performance goal. These codes should be listed on the same claim as the payable code with which they are associated (e.g., report G9891 for sessions 2 and 3 if you are reporting G9874 for session 4 attendance)

• Each HCPCS G-code should be listed with the corresponding session date of service and rendering coach National Provider Identifier (NPI)

• If a beneficiary switches suppliers, the new supplier may receive a bridge payment (G9890) for the first MDPP session furnished to that beneficiary. More than one supplier may claim a bridge payment for the same beneficiary

• The Virtual Modifier, “VM”, should be appended to the end of any G-code that is associated with a session that was furnished as a virtual make-up session (e.g., G9891VM)