Q&A: How to understand the new diabetes code for primary care

Q: Can you explain the intensive behavior therapy code for treating patients with diabetes? Is this a new code?

A: This new Category III CPT code, 0403T, became effective January 1, 2016, and will be used to report the services provided in a standardized diabetes prevention program (DPP) recognized by the Centers for Disease Control and Prevention (CDC). 

This code should be billed when a provider conducts a face-to-face intensive behavior change therapy session in a group setting, aimed at diabetes prevention using standard program parameters. It is reported for a minimum of 60 minutes per day of intense therapy.

The standardized curricula recognized by the CDC are year-long behavior change interventions comprised of at least 24 sessions distributed across the course of a year. Typically they are provided in 16 weekly, hour-long sessions for the first six months of the year, followed by monthly hour-long sessions during the second six months.

Recent studies have shown several behavioral adjustments can be made in order to help prevent type 2 diabetes in those at high risk, specifically those patients with minimal physical activity and obesity.

However, this is not just a weight-loss program.  Specific eligibility criteria include laboratory blood values or risk factors, including genetic predisposition, that indicate a high risk for type 2 diabetes. 

Throughout the behavior change intervention, participants have access to a trained coach who must be able to provide the program successfully. These coaches are trained in collection of weight data, physical activity, food journal review, behavior change strategies, motivational interviewing and more.

Participants are weighed at every session and work toward goals of healthier eating,150 minutes per week of physical activity, and 5% to 7% or more weight loss. Participants also collaboratively discuss and identify solutions to health and behavior challenges for type 2 diabetes risk reduction. 

Here are some coding tips for using CPT code 0403T: 

This code should be used only by CDC-recognized National DPP providers. An insurer could require verification that services were rendered by a CDC-recognized National DPP provider.

For reimbursement, a CDC-recognized National DPP provider must negotiate a fee with a payer. If a payer receives a claim for a Category III code and a provider has not negotiated a fee, there is no assumed reimbursement. It is merely a reporting code to say that a health plan member is receiving the services of a CDC-recognized National DPP provider.

Prior to reimbursement being negotiated, it is still important for CDC-recognized National DPP providers to submit a claim when possible for all insured individuals participating in the program.