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Date Printed: October 23, 2017: 07:21 AM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

01-99000-02

Original Effective Date: 11/15/01

Reviewed: 01/25/07

Revised: 10/01/16

Subject: Diabetic Self-Management Training and Educational Supplies

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates  
           

DESCRIPTION:

Diabetes mellitus is a condition of abnormal glucose metabolism. Diabetes mellitus is classified according to two syndromes: Type 1 diabetes and Type 2 diabetes. Type 1 diabetes is characterized by beta cell destruction, usually leading to absolute insulin deficiency. Type 2 diabetes is a term for individuals who have insulin resistance and usually have relative (rather than absolute) insulin deficiency.

Pre-diabetes is defined as blood glucose levels that are higher than normal, but not high enough to be diagnosed as Type 2 diabetes.

There are several ways to diagnose diabetes and prediabetes. The A1C test measures average blood glucose for the previous 2 to 3 months. The Fasting Plasma Glucose (FPG) test checks blood glucose levels after fasting at least 8 hours. The Oral Glucose Tolerance Test (OGTT) is a two-hour test that checks blood glucose levels before and 2 hours after a glucose drink is consumed. The Random (Casual) Plasma Glucose Test is a blood check at any time of the day.

According to the American Diabetes Association, diabetes is diagnosed:

According to the American Diabetes Association, pre-diabetes is diagnosed:

Since diabetes is a chronic illness, the individual requires continual medical care and education in order to prevent acute complications and delay the risk of long-term medical problems. A critical element for the successful treatment of all individuals with diabetes is participation in a comprehensive self-management care and education program. Ongoing support, maintenance, and modifications in treatment regimes and lifestyle changes all require continued individual and caregiver participation.

A diabetes outpatient self-management training (DSMT) service is a program that educates individuals in the successful self-management of diabetes. An outpatient diabetes self-management and training program includes education about self-monitoring of blood glucose, diet and exercise, an insulin treatment plan developed specifically for the patient who is insulin-dependent, and it motivates individuals to use the skills for self-management.

POSITION STATEMENT:

Diabetic self-management training and the related educational supplies meet the definition of medical necessity when ALL of the following criteria are met:

NOTE: Self-referral to a diabetic self-management training program is not covered.

BILLING/CODING INFORMATION:

The following codes may be used to describe diabetic self-management training and educational supplies:

CPT Coding:

98960

Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient

98961

Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; 2-4 patients

98962

Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; 5-8 patients

99078

Physician or other qualified health care professional qualified by education, training, licensure/regulation (when applicable) educational services rendered to patients in a group setting (e.g., prenatal, obesity, or diabetic instructions)

HCPCS Coding:

G0108

Diabetes self-management training services, individual, per 30 minutes

G0109

Diabetes self-management training services, group session (2 or more), per 30 minutes

S9140

Diabetic management program, follow-up visit to non-MD provider

ICD-10 Diagnoses Codes That Support Medical Necessity: (Effective 10/01/15)

E08.00 – E13.9

Diabetes mellitus

E88.81

Metabolic syndrome

O24.011 – O24.93

Diabetes mellitus in pregnancy, childbirth and the puerperium

O99.810 – O99.815

Abnormal glucose complicating pregnancy, childbirth and the puerperium

R73.01 – R73.9

Elevated blood glucose level

REIMBURSEMENT INFORMATION:

Initial self-management training is limited to 10-12 hours of training within a continuous 12-month period; 9 of the 10 – 12 hours must be provided in a group setting unless special conditions exist preventing the member from attending group sessions (i.e., no group sessions are available within 2 months of the date of the physician’s order; the member has special needs relating to problems with hearing, vision, or language limitations; additional instruction is needed in administering insulin).

Follow-up training is limited to 2 hours of training each year, beginning with the calendar year following the year in which the member completed initial self-management training.

Reimbursement for nutritional counseling by a licensed dietitian is included in the allowance for the training/education services.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

The following National Coverage Determination (NCD) was reviewed on the last guideline reviewed date: Diabetes Outpatient Self-Management Training (40.1) located at cms.gov.

The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Diabetes Outpatient Self-Management Training (L29133) located at fcso.com.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

Medical Nutrition Therapy, 01-99000-05

OTHER:

Florida Statute 641.31 (26) (a, b, c): Health Care Service Programs; Health Maintenance Organizations

a) Each health maintenance organization and prepaid health plan shall provide coverage for all medically appropriate and necessary equipment, supplies, and services used to treat diabetes, including outpatient self-management training and educational services, if the patient's primary care physician, or the physician to whom the patient has been referred who specializes in treating diabetes, certifies that the equipment, supplies, or services are necessary.

b) The contract may require that diabetes outpatient self-management training and educational services are provided under the direct supervision of a certified diabetes educator or a board-certified endocrinologist under contract with or designated by the health maintenance organization or prepaid health plan.

c) The Agency for Health Care Administration shall adopt standards for outpatient self-management training and educational services, taking into consideration standards approved by the American Diabetes Association.

Florida Administrative Rule 59B-17.001: Diabetes Outpatient Self-Management Training and Educational Services Standards

All health insurance policies, group health insurance policies and health maintenance contracts subject to the requirements of Sections 627.6408, 627.65745 and 641.31, F.S., shall provide, if the patient’s treating provider or a provider who specializes in the treatment of diabetes certifies that such services are necessary: diabetes outpatient self-management training and education services based on the current standards endorsed by the American Diabetes Association as outlined in the “National Standards for Diabetes Self-Management Education and Support” published in Diabetes Care, September 20, 2012, which is incorporated by reference.

REFERENCES:

  1. Agency for Health Care Administration (AHCA) Diabetes Practice Guidelines; Self-Management Training.
  2. American Diabetes Association. Diabetes Basic (Prevention): Prediabetes. Accessed at http://www.diabetes.org/ on 07/29/13.
  3. American Medical Association CPT (current edition).
  4. Centers for Medicare & Medicaid Services. National Coverage Determination (NCD) for Diabetes Outpatient Self-Management Training (40.1). 02/27/01.
  5. First Coast Service Options, Inc. (FCSO). Local Coverage Determination: Diabetes Outpatient Self-Management Training (L29133). 02/02/09.
  6. Florida Administrative Register & Florida Administrative Code. Rule 59B-17.001: Diabetes Outpatient Self-Management Training and Educational Services Standards. June 25, 2013.
  7. Florida Medicare Part B Medical Policy # G0108, Diabetes outpatient Self-Management Training, 02/27/01.
  8. Florida Statutes, 641.31 (26)(a, b, c).
  9. Haas L, et. al. National Standards for Diabetes Self-Management Education and Support. The Diabetes Educator 2012 38: 619. September 20, 2012.
  10. HCPCS Level II Codes (current edition).
  11. Medicare Coverage Issues Manual, (CIM 80-2). 06/01.
  12. Medicare Program Memorandum B-01-40, Change Request 1455, dated 06/15/01.
  13. St. Anthony’s ICD-9-CM Code Book 2001, 6th Edition.
  14. State of Florida, Agency for Health Care Administration: Diabetes, Medical Practice Guidelines (Endorsed 10/01 under the authority of the Florida Health Care and Insurance Reform Act of 1993, Section 408.02, Chapter 93-129, Laws of Florida.)
  15. The American Association of Clinical Endocrinologists Medical Guidelines for the Management of Diabetes Mellitus: The AACE System of Intensive Diabetes Self-Management, 2002 Update. Developed by the American Association of Clinical Endocrinologists and the American College of Endocrinology, 2002. Endocrine Practice Vol. 8 (Suppl. 1) January/February 2002.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 07/30/13.

GUIDELINE UPDATE INFORMATION:

11/15/01

Medical Coverage Guideline Reformatted and Revised.

10/01/02

Local codes removed.

11/15/02

Reimbursement information corrected; reference added.

10/15/03

Scheduled review; no change in coverage statement.

02/15/07

Revision consisting of the addition of ICD-9 diagnosis codes for gestational diabetes.

06/15/07

Reformatted guideline; updated references.

10/15/10

Revision; related ICD-10 codes added.

12/15/10

Revision; deleted CPT codes 99071, S9455, S9460 and S9465.

01/01/13

Annual CPT coding update. Revised code descriptor for 99078.

08/01/13

Revision; revised Description and Position Statement, ICD9 and ICD10 coding and Program Exceptions. Added Florida Administrative Rule 59B-17.001. Updated references and reformatted guideline.

06/15/14

Revision; added code S9140.

05/15/15

Revision; added codes 98960, 98961, 98962.

11/01/15

Revision: ICD-9 Codes deleted.

10/01/16

ICD-10 coding update: added codes R73.01 – R73.9.

DECISION TREE:

Date Printed: October 23, 2017: 07:21 AM