Commercial Diabetes Prevention Program (DPP)

The Diabetes Prevention Program expanded model is a structured intervention with the goal of preventing progression to type 2 diabetes in individuals with an indication of pre-diabetes. The clinical intervention consists of an minimum of 16 intensive “core” sessions of a Centers for Disease Control and Prevention (CDC) approved curriculum furnished over six months in a group-based, classroom-style setting that provides practical training in long-term dietary change, increased physical activity, and behavior change strategies for weight control.

The primary goal of the expanded model is at least 5 percent weight loss by participants.

This program is modeled after the Medicare Diabetes Prevention Program, so eligibility requirements, program description, and payment codes will be similar. The program is also designed to be once-in-a-lifetime benefit.

Program to start for EUTF Active members on 7/1/18 and all other eligible employer groups upon renewal in 2019. All Federal Plan 87 members are eligible January 1, 2023. All HMSA Plan for Postal Service Employees members will be eligible January 1, 2025.

Learn more. Visit the Centers for Disease Control and Prevention (CDC) website.

Who’s Eligible?

• Must be 18 years or older
• Have a body mass index (BMI) greater than 23 for Asians or more than 25 for others.
• Have blood test results within 12 months before enrolling in the program that show:
  • Hemoglobin A1c of 5.7 percent to 6.4 percent; or
  • Fasting plasma glucose of 100 -125 mg/dL; or
  • Two-hour plasma glucose of 140-199 mg/dL.
• Have no history of diabetes or End-Stage Renal Disease (ESRD). History of gestational diabetes is allowed.

Find a Credentialed Provider

Call customer service for more information.

Interested in being an DPP service provider?

Register with the CDC and CMS. The provider credentialing will remain the same as MDPP. Get started using the MDPP Orientation Roadmap[PDF].

Want to join HMSA’s provider network?

Visit the HMSA Provider Resource Center.

Coding DPP Services effective January 1, 2024

Members whose services started prior to 2023 will need to bill with the new codes above for services in 2024.

Coding DPP Services prior to January 1, 2024

Billing MDPP services

• Indicate the most recent service date for multi-date services on the payable code.
• Always include G9891 to report attendance of each session that is not associated with a performance goal.
• When billing for the initial visit (G9873) for enrollment into the program, please be sure to include the following diagnoses:
  • A diagnosis that accurately indicates the patient’s BMI
    • Z68.23 , Z68.24, Z68.25, Z68.26, Z68.27, Z68.28, Z68.29, Z68.30, Z68.31, Z68.32, Z68.33, Z68.34, Z68.35, Z68.36, Z68.37, Z68.38, Z68.39, Z68.41, Z68.42, Z68.43, Z68.44, Z68.45
  • A diagnosis to indicate abnormal glucose levels
    • R73.01, R73.02, R73.03, R73.09
• Note that billable codes representing multiple sessions should only be billed with G9891 service dates that have not already been billed and reported.
• If a DPP beneficiaries started their first core session on or after January 1, 2022, ongoing maintenance sessions (HCPCS codes G9882, G9883, G9884, and G9885) should not be billed

For example, a claim for G9874 would include four service lines with appropriate dates of service. G9874 is billed with the service date for the most recent session. To prevent processing delays, please don’t submit payable codes with different “from” and “to” dates.

Since G9874 indicates four total sessions have been completed, two G9891 codes must be included on the claim, each with a specific service date. G9874 would be the service date of the fourth visit, while the first visit would have been billed previously using G9873.

• If reporting a make-up session that occurred on the same date of service as a regularly scheduled session, do not report two separate line items. Bill one line for G9891 with a unit of 2.
• If reporting a virtual make-up session, append the virtual modifier (modifier –VM) to G9891 for the appropriate date.
• Should you receive a patient from another DPP service provider, when submitting a claim for the bridge payment (G9890), please be sure to include notes that indicate the patient meets program eligibility criteria.
• For all bridge payments (G9890), please submit on a separate claim form from all other HCPC codes.

A few reminders

• To continue to the second year of the program, your patients must achieve at least 5 percent weight loss from baseline. HMSA won't cover second-year services unless G9878, G9879, and/or G9880 has been submitted as evidence of eligibility.
• When billing for DPP services, please be aware of all program limitations and specifics such as class frequencies and use of virtual services. Program details are available at the CMS website.
• Please verify that your patients continue to meet program requirements throughout the two-year program.
• HMSA conducts periodic reviews to ensure that program and eligibility criteria are properly met.

Revision History