Referral Process

Team-based approach

Referring and treating a person with diabetes requires a team-based approach. The most successful DSMES services clearly define each team member's roles and responsibilities.

For example, one team member may be responsible for processing all incoming DSMES service referrals, while another is responsible for follow-up with the referring provider. Referring providers, diabetes care and education specialists, and DSMES service staff can use tracking systems and reminders to manage attendance and follow-up.

Participant eligibility

Note: The Centers for Medicare & Medicaid Services (CMS) uses the term “training” (DSMT) instead of “education and support” (DSMES) when defining the reimbursable benefit (DSMT). This term relates specifically to Medicare billing.

To qualify for DSMT coverage, a participant must have a documented diagnosis of type 1, type 2, or gestational diabetes and meet the criteria below. Diagnosis can occur before Medicare Part B enrollment.

Diagnosis criteria

The participant must also have a written referral from the treating physician or a qualified nonphysician practitioner. Nonphysician practitioners include physician assistants, nurse practitioners, and advanced practice nurses.

When to refer

In 2020, a group of professional and medical associations issued a joint consensus statement. This statement focused on the importance of DSMES in type 2 diabetes. The statement includes evidence-based information on four critical times to refer people with type 2 diabetes to DSMES services:

1. At diagnosis
2. Annually (or when not meeting treatment targets)
3. When complicating factors develop
4. When a transition in life or care happens

Referral requirements and documentation

DSMES services are covered by Medicare for enrolled recipients if the treating physician or qualified practitioner documents the need for DSMES in a referral or order.

There are many documentation requirements for referrals. Depending on the place of service (e.g., Federally Qualified Health Center, rural health center, hospital), extra or different documentation may be required.

The referring provider must keep the care plan and supporting documentation in the participant's medical record. They should also sign any changes to the order.

The DSMES service must retain the original referral and any other special conditions noted by the referring practitioner. The DSMES service should also retain a record of any changes to the order signed by a referring provider.

Sample referral forms

• DSMES/T Sample Order Form
• Sample Short Referral Form

Resources

See these resources for more information on referral requirements and documentation.

• DSMES/T and Medical Nutrition Therapy (MNT) Services
• Diabetes Self-Management Training (DSMT) Accreditation Program