Medicare Diabetes Prevention Program

Diabetes in adults 18-79 is expected to increase more than 200% by 2050. To combat this trend, Medicare established coverage for the Medicare Diabetes Prevention Program. To be eligible for reimbursement, organizations must enroll, follow the prescribed electronic program, and document success achieved and maintained. Billable HCPCS must be reported to track success over time and identify both the weight lost and how long weight loss has been maintained. The benefit is once per lifetime, meaning each code can only be reported once per patient by any provider.  Eligible patients must meet the following requirements:

  • Enrolled in Medicare Part B
  • Have a body mass index (BMI) of at least 25, or at least 23 if self-identified as Asian
  • Meet 1 of the following 3 blood test requirements within the 12 months of the first core session:
    • A hemoglobin A1c test with a value between 5.7 and 6.4%, or
    • A fasting plasma glucose of 110-125 mg/dL, or
    • A 2-hour plasma glucose of 140-199 mg/dL (oral glucose tolerance test)
  • Have no previous diagnosis of type 1 or type 2 diabetes (other than gestational diabetes)
  • Do not have end-stage renal disease (ESRD)

Services should be reported using HCPCS – G9873 – G9891 to track visits and patient success.

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