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Claim Payment Policy

Title:Outpatient Diabetes Education and Self-Management Training

Policy #:12.05.01f


Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.


Intent
The intent of this policy is to communicate the Company’s coverage and reimbursement position for outpatient diabetes education and self-management training.

For information on policies related to this topic, refer to the Cross References section in this policy.
Description
Outpatient diabetes education and self-management training is a formalized, comprehensive outpatient program that teaches individuals who have been diagnosed with diabetes about their diagnosis and its treatment. Components of such programs include, but are not limited to:
  • Blood glucose self-monitoring
  • Dietary requirements
  • Exercise and its role in the management of diabetes
  • If necessary, instruction on the self-administration of pharmaceutical agents for the treatment of diabetes
Outpatient diabetes education and self-management training is performed by a provider who is certified by the National Certification Board for Diabetes Educators (NCBDE) as a certified diabetes educator (CDE). A diabetes educator is defined under state requirements as a professional who is licensed, certified, or registered to provide diabetes education in the state where the services are performed.
Policy
Outpatient diabetes education and self-management training is covered by the Company and eligible for reimbursement consideration when all of the following requirements are met:
  • The training is performed in one of the following settings:
    • Hospital outpatient
    • Outpatient freestanding program
    • Professional provider office (eg, primary care physician [PCP], endocrinologist, obstetrical specialty)
  • The education and training is provided by one of the following:
    • A Company-contracted, outpatient diabetes education program (either hospital-based or freestanding) that is recognized by the state Department of Health or the American Diabetes Association as meeting the National Standards for Diabetes Patient Education Programs established by the National Diabetes Advisory Board, with the following exception:
      • For Medicare Advantage and New Jersey (NJ) products that allow coverage of services provided by noncontracted providers, these services may be provided according to the guidelines of the individual's benefit contract.
    • A certified diabetes educator (CDE) who is practicing in a participating provider office, with the following exception:
      • For Medicare Advantage and NJ products that allow coverage of services provided by nonparticipating providers, these services may be provided according to the guidelines of the individual's benefit contract.
  • The individual is diagnosed with diabetes, as identified by one of the following:
    • Diabetes mellitus; type I
    • Diabetes mellitus; juvenile type
    • Diabetes mellitus; type II
    • Insulin-dependent diabetes mellitus (IDDM)
    • Non-insulin-dependent diabetes mellitus (NIDDM)
    • Gestational diabetes (insulin- or non-insulin-dependent)
    • Maternal diabetes mellitus
    • Abnormal maternal glucose tolerance
    • Neonatal diabetes mellitus
  • The education and training is provided to the individual upon any of the following:
    • The initial diagnosis of diabetes
    • A significant change in the individual’s diabetes-related symptoms or condition
    • The introduction of a new medication or therapy in the treatment or management of the individual’s diabetes
Services that do not meet the requirements in this policy or those that exceed the product and/or state benefit limitations are not eligible for reimbursement by the Company.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the health care professional's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Guidelines
The Company considers diabetes education and self-management training performed in the home setting by a home health agency to be an integral part of the home care visit and is, therefore, not eligible for separate reimbursement consideration. For information regarding diabetes education and self-management training performed in the home setting for individuals with gestational diabetes, please contact the Company's Maternal Case Management Program.

At times, it may be necessary to allow a parent, guardian, or significant other of the individual diagnosed with diabetes to attend outpatient diabetes education and self-management training. In such cases, providers (ie, hospital outpatient programs, freestanding outpatient programs, professional provider office-based programs) should report the diabetes education and self-management training services on the claim form for the individual diagnosed with diabetes, regardless of who attends the program.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, outpatient diabetes education and self-management training is covered under the medical benefits of the Company’s products.

MEDICARE

This policy is consistent with Medicare's coverage determination. The Company's payment methodology may differ from Medicare.

MANDATES

This policy is consistent with applicable state mandates. The laws of the state in which the group benefit contract is issued determine the applicable legislatively mandated coverage.

References
American Diabetes Association. Standards of medical care in diabetes--2009. Diabetes Care(serial online). 2009;32:S13-S61. [Diabetes Care Web site]. Available at: http://care.diabetesjournals.org/content/32/Supplement_1/S13.full.pdf+html?sid=f2d1ac68-b09b-438e-95be-f132dc2e5dbf. Accessed May 26, 2009.

Centers for Medicare & Medicaid Services (CMS). Coverage Issues Manual. Part 80: Patient education programs. §80-2: Outpatient diabetic education programs. [CMS Web site]. September 2004. Available at: http://www.cms.hhs.gov/manuals/downloads/Pub06_PART_70.pdf. Accessed May 26, 2009.

Company Benefit Contracts.

Funnell MM, Brown TL, Childs BP, et al. National standards for diabetes self-management education. Diabetes Care(serial online). 2009;32:S87-S94. [Diabetes Care Web site]. Available at: http://care.diabetesjournals.org/content/32/Supplement_1/S87.full.pdf+html?sid=383bcb1b-7573-403d-9541-98f062e2c19b. Accessed May 26, 2009.

General Assembly of Pennsylvania. PA Insurance Company Law of 1921. Act 98 of 1998. H656;§633: Reimbursement for diabetic supplies. [Pennsylvania General Assembly Web site]. 10/16/98. Available at: http://www2.legis.state.pa.us/WU01/LI/BI/BT/1997/0/SB1156P1391.pdf. Accessed May 26, 2009.

National Certification Board for Diabetes Educators (NCBDE). Eligibility requirements. [NCBDE Web site]. Available at: http://www.ncbde.org/eligibility.cfm. Accessed May 26, 2009.

New Jersey Legislature. NJ Permanent Statutes. Title 17:48-6n: Coverage for diabetes treatment by individual, group hospital service corporation. [New Jersey Legislature Web site]. Available at: http://www.njleg.state.nj.us/. Accessed May 26, 2009.

New Jersey Legislature. NJ Permanent Statutes. Title 17:48A-7l: Coverage for diabetes treatment by individual, group medical service corporation. [New Jersey Legislature Web site]. Available at: http://www.njleg.state.nj.us/. Accessed May 26, 2009.

New Jersey Legislature. NJ Permanent Statutes. Title 17:48E-35.11: Coverage for diabetes treatment by individual group health service corporation. [New Jersey Legislature Web site]. Available at: http://www.njleg.state.nj.us/. Accessed May 26, 2009.

New Jersey Legislature. NJ Permanent Statutes. Title 17B:26-2.1l: Coverage for diabetes treatment by individual health insurance policy. [New Jersey Legislature Web site]. Available at: http://www.njleg.state.nj.us/. Accessed May 26, 2009.

New Jersey Legislature. NJ Permanent Statutes. Title 17B:27-46.1m: Coverage for diabetes treatment by group health insurance policy. [New Jersey Legislature Web site]. Original: 1995. (Revised: 2001). Available at: http://www.njleg.state.nj.us/. Accessed May 26, 2009.

New Jersey Legislature. NJ Permanent Statutes. Title 26:2J-4.11: Coverage for diabetes treatment by HMO contracts. [New Jersey Legislature Web site]. Available at: http://www.njleg.state.nj.us/. Accessed May 26, 2009.

US Department of Health & Human Services. Your Medicare Coverage. New Jersey. Diabetic services. [Medicare.gov Web site]. 05/08/09. Available at: http://www.medicare.gov/Coverage/Search/Results.asp?State=NJ%7CNew+Jersey&Coverage=122%7CDiabetes+Self-Management+Training&submitState=View+Results+%3E. Accessed May 26, 2009.

US Department of Health & Human Services. Your Medicare Coverage. Pennsylvania. Diabetic services. [Medicare.gov Web site]. 05/08/09. Available at: http://www.medicare.gov/Coverage/Search/Results.asp?State=PA%7CPennsylvania&Coverage=18%7CDiabetic+Services&submitState=View+Results+%3E. Accessed May 26, 2009.
Coding Table

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

Code SystemCode Number(s) and Narrative(s)
CPT98960, 98961, 98962, 99078
ICD ProcedureN/A
ICD Diagnosis249.00: Secondary diabetes mellitus without mention of complication, not stated as uncontrolled, or unspecified

249.01: Secondary diabetes mellitus without mention of complication, uncontrolled

249.10: Secondary diabetes mellitus with ketoacidosis, not stated as uncontrolled, or unspecified

249.11: Secondary diabetes mellitus with ketoacidosis, uncontrolled

249.20: Secondary diabetes mellitus with hyperosmolarity, not stated as uncontrolled, or unspecified

249.21: Secondary diabetes mellitus with hyperosmolarity, uncontrolled

249.30: Secondary diabetes mellitus with other coma, not stated as uncontrolled, or unspecified

249.31: Secondary diabetes mellitus with other coma, uncontrolled

249.40: Secondary diabetes mellitus with renal manifestations, not stated as uncontrolled, or unspecified

249.41: Secondary diabetes mellitus with renal manifestations, uncontrolled

249.50: Secondary diabetes mellitus with ophthalmic manifestations, not stated as uncontrolled, or unspecified

249.51: Secondary diabetes mellitus with ophthalmic manifestations, uncontrolled

249.60: Secondary diabetes mellitus with neurological manifestations, not stated as uncontrolled, or unspecified

249.61: Secondary diabetes mellitus with neurological manifestations, uncontrolled

249.70: Secondary diabetes mellitus with peripheral circulatory disorders, not stated as uncontrolled, or unspecified

249.71: Secondary diabetes mellitus with peripheral circulatory disorders, uncontrolled

249.80: Secondary diabetes mellitus with other specified manifestations, not stated as uncontrolled, or unspecified

249.81: Secondary diabetes mellitus with other specified manifestations, uncontrolled

249.90: Secondary diabetes mellitus with unspecified complication, not stated as uncontrolled, or unspecified

249.91: Secondary diabetes mellitus with unspecified complication, uncontrolled

250.00: Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled

250.01: Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled

250.02: Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled

250.03: Diabetes mellitus without mention of complication, type I [juvenile type], uncontrolled

250.10: Diabetes with ketoacidosis, type II or unspecified type, not stated as uncontrolled

250.11: Diabetes with ketoacidosis, type I [juvenile type], not stated as uncontrolled

250.12: Diabetes with ketoacidosis, type II or unspecified type, uncontrolled

250.13: Diabetes with ketoacidosis, type I [juvenile type], uncontrolled

250.20: Diabetes with hyperosmolarity, type II or unspecified type, not stated as uncontrolled

250.21: Diabetes with hyperosmolarity, type I [juvenile type], not stated as uncontrolled

250.22: Diabetes with hyperosmolarity, type II or unspecified type, uncontrolled

250.23: Diabetes with hyperosmolarity, type I [juvenile type], uncontrolled

250.30: Diabetes with other coma, type II or unspecified type, not stated as uncontrolled

250.31: Diabetes with other coma, type I [juvenile type], not stated as uncontrolled

250.32: Diabetes with other coma, type II or unspecified type, uncontrolled

250.33: Diabetes with other coma, type I [juvenile type], uncontrolled

250.40: Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled

250.41: Diabetes with renal manifestations, type I [juvenile type], not stated as uncontrolled

250.42: Diabetes with renal manifestations, type II or unspecified type, uncontrolled

250.43: Diabetes with renal manifestations, type I [juvenile type], uncontrolled

250.50: Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled

250.51: Diabetes with ophthalmic manifestations, type I [juvenile type], not stated as uncontrolled

250.52: Diabetes with ophthalmic manifestations, type II or unspecified type, uncontrolled

250.53: Diabetes with ophthalmic manifestations, type I [juvenile type], uncontrolled

250.60: Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled

250.61: Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled

250.62: Diabetes with neurological manifestations, type II or unspecified type, uncontrolled

250.63: Diabetes with neurological manifestations, type I [juvenile type], uncontrolled

250.70: Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as uncontrolled

250.71: Diabetes with peripheral circulatory disorders, type I [juvenile type], not stated as uncontrolled

250.72: Diabetes with peripheral circulatory disorders, type II or unspecified type, uncontrolled

250.73: Diabetes with peripheral circulatory disorders, type I [juvenile type], uncontrolled

250.80: Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled

250.81: Diabetes with other specified manifestations, type I [juvenile type], not stated as uncontrolled

250.82: Diabetes with other specified manifestations, type II or unspecified type, uncontrolled

250.83: Diabetes with other specified manifestations, type I [juvenile type], uncontrolled

250.90: Diabetes with unspecified complication, type II or unspecified type, not stated as uncontrolled

250.91: Diabetes with unspecified complication, type I [juvenile type], not stated as uncontrolled

250.92: Diabetes with unspecified complication, type II or unspecified type, uncontrolled

250.93: Diabetes with unspecified complication, type I [juvenile type], uncontrolled

648.00: Maternal diabetes mellitus, complicating pregnancy, childbirth, or the puerperium; unspecified as to episode of care

648.01: Maternal diabetes mellitus with delivery

648.02: Maternal diabetes mellitus with delivery, with current postpartum complication

648.03: Maternal diabetes mellitus, antepartum

648.04: Maternal diabetes mellitus, previous postpartum condition

648.80: Abnormal maternal glucose tolerance, complicating pregnancy, childbirth, or the puerperium; unspecified as to episode of care

648.81: Abnormal maternal glucose tolerance, with delivery

648.82: Abnormal maternal glucose tolerance, with delivery, with current postpartum complication

648.83: Abnormal maternal glucose tolerance, antepartum

648.84: Abnormal maternal glucose tolerance, previous postpartum condition

775.1: Neonatal diabetes mellitus
HCPCS Level IIG0108: Diabetes outpatient self-management training services, individual, per 30 minutes

G0109: Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes

S9140: Diabetic management program, follow-up visit to non-MD provider

S9141: Diabetic management program, follow-up visit to MD provider

S9455: Diabetic management program, group session

S9460: Diabetic management program, nurse visit

S9465: Diabetic management program, dietitian visit
Revenue Codes942: Education/Training
      Cross References
      Version Effective Date: 10/01/2008
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      The Policy Bulletins on this web site were developed to assist AmeriHealth and its subsidiaries ("AmeriHealth") in administering the provisions of the respective benefit programs, and do not constitute a contract. If you are an AmeriHealth member, please refer to your specific benefit program for the terms, conditions, limitations and exclusions of your coverage. AmeriHealth does not provide health care services, medical advice or treatment, or guarantee the outcome or results of any medical services/treatments. The facility and professional providers are responsible for providing medical advice and treatment. Facility and professional providers are independent contractors and are not employees or agents of AmeriHealth. If you have a specific medical condition, please consult with your doctor. AmeriHealth reserves the right at any time to change or update its Policy Bulletins. ©2012 AmeriHealth, Inc. All Rights Reserved.  Current Procedural Terminology ©2012 American Medical Association. All Rights Reserved.
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