This guidance is designed to assist community-based organizations in developing their policies and procedures or step-by-step processes to ensure quality documentation and billing for the following Medicare Part B benefits: Diabetes Self-Management Training (DSMT), Chronic Care Management (CCM), and Health and Behavior Assessment and Intervention (HBAI).

Generally, each organization has a template for formalizing and documenting programmatic processes. We recommend that you print this document to guide you in developing formalized, written processes. Then, use your organization’s template or format to write a step-by-step process for each of the items listed below.

Your process should include who is responsible for what and when. Additionally, you should include what your process is for monitoring and evaluation to ensure quality services and to protect your organization in case of an audit.

1. HIPAA Training

What is your process for providing HIPAA training and compliance for all individuals involved in the delivery (licensed clinician, lay leaders, health coaches, etc.) or support (includes back-office staff and supervisors) of Medicare Part B services?

Checklist of Items to include in this process:

• How you will ensure confidentiality and protect the privacy and security of health information, including the health record itself, whether electronic or paper-based.
• What your policy is for retention of health information.  Policy for refresher training on HIPAA (frequency).
• Other: 

2. Clinician’s Responsibilities

What are the clinician’s responsibilities for documentation and billing? What training is necessary to perform these responsibilities? What is your process for training and monitoring this process?

Checklist of Items to Include in this process:

• Ensuring that the clinician’s NPI is linked to the Medicare provider (i.e., the provider transaction access number/PTAN) before implementing the services.
• 15 hours of continuing education units (CEUs) annually to meet the national Standards for Diabetes Self-Management Education Services (DSMES) accreditation (DSMT only).
• Training specific to Medicare Part B benefit, including the CDSME program curriculum and the action planning/feedback/problem solving process.
• The expectations for supervision and oversight of the services provided by other members of the clinical team, including countersignature of each encounter note.
• The documentation responsibilities and flow, including the referring provider’s order and confirmation of diabetes (for DSMT), initial assessment, individualized education/care plan, individual and group interventions, reassessment, written options and resources for ongoing DSMES support (for DSMT), and any other requirements specific to the Medicare benefit.
• Use of the superbill or electronic process for documenting service time and codes and communication with back-office staff.
• Communication, coordination, and flow of information between the licensed clinician/provider and the lay leaders/health coaches.
• Timeliness requirements for documentation.
• Monitoring and quality assurance to ensure compliance with the process.
• Other:

3. Lay leaders/Health Coaches’ Responsibilities

What is your process for training and monitoring the lay leaders’/health coaches’ responsibilities for documentation and billing?

Checklist of Items to Include in this process:

• What qualifications and training are necessary to carry out the health coach/lay leader responsibilities:
• What qualifications and training are required for the lay leader/health coach role.
• What your process is for orientation and training lay leaders/health coaches to understand their responsibilities, including documentation requirements and workflow.
• 15 hours of continuing education annually to meet the national Standards for accreditation (for DSMT).
• Documentation of the weekly action planning/goal setting process when the CDSME program is an intervention included in the individualized education/care plan.
• Supervision for the services provided and documented.
• How the documentation will be monitored to ensure compliance and quality services.
• Communication, coordination, and flow of information between lay leaders/health coaches and licensed clinician/qualified provider.
• Timeliness.
• Use of the superbill or electronic process for documenting service time and codes and communication/coordination with back-office staff.
• Other:

4. Pre-Billing Preparation

What is your pre-billing process?

Checklist of items to include in this process:

• Ensure each provider is credentialed with the billing PTAN prior to service initiation. Each billing provider must have a signed 855R on file with the MAC.
• If providing DSMT, ensure that proof of accreditation has been submitted.
• If services require a referral, ensure that a referral is on file that predates the initiation of services.
• Capture the NPI of the referring provider.
• Review the charge capture process with each person that will interface with participants, prior to the initiation of services.
• Other

5. Check-In

What is your check-in process?

Checklist of items to include in this process:

• Confirm that a completed referral is on file with the NPI of the referring provider (if needed)
• Verify the individual’s identification.
• Obtain a copy of the primary insurance card.
• Obtain a copy of the secondary insurance card.
• Scan and/or copy the insurance cards.
• If the individual does not have a Medigap policy, educate the member about their responsibility to cover the co-insurance amount.
• If the beneficiary cannot pay the required co-insurance amount, document the response regarding the inability to pay in the record.
• Establish a process for individuals who are uninsured.
• Create an encounter form (i.e., superbill) for each individual.
• Place a copy of each person’s encounter form in the health record for the licensed clinician or provider to complete at the time services are rendered.
• Other:

6. End-of-Day

What is your end-of-day billing process?

Checklist of items to include in this process:

• At the completion of each encounter/class session, how you will ensure that participant’s encounter form is completed to document the services rendered and the number of billable units provided.
• The billing provider’s process for confirming the services and volume of services that should be filed for reimbursement per beneficiary.
• Process for the billing provider to ensure that proper documentation is on file for each person for which services will be billed.
• Other:

7. Post-Claim Follow Up

What is your process for post-claim follow up?

Checklist of items to include in this process:

• Monitor for explanation of benefits (EOBs).
• How you will track denials of claims.
• How you will correct denials in a timely manner and resubmit the claims.
• Monitor for revised EOBs after denials are resubmitted.
• Track denial reasons for corrective action and training.
• Track progress towards break-even and adjust as necessary to meet break-even goals.
• Other:

This project was supported, in part by grant number 90CS0058, from the U.S. Administration for Community Living, Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official Administration for Community Living policy.