Diabetes management

Applies to members of:

All plans

Definition

A disease in which the body produces too little or no insulin, or insulin is produced but the body can't use it. This results in high levels of sugar in the blood.

Medical policy

Also see

Medicare authorizations for diabetes testing supplies

To prescribe more than the approved limit of diabetes testing supplies for Medicare Advantage plan members, a Pre-Service Organization Determination (PSOD) is required. A PSOD is equivalent to the Advance Beneficiary Notice (ABN) used by Original Medicare, but under Part C Medicare rules it must be issued by Priority Health.

The provider should document if a member is not insulin dependent.

Diabetes Self-Management Education and Training (DSMES) program

Overview

Diabetes self-management training teaches members to cope, control and manage diabetes. The program may include tips for eating healthy and being active, monitoring blood glucose (blood sugar), use of devices, taking prescription drugs and reducing risks. Some patients may also be eligible for medical nutrition therapy services.

Authorizations

A written order from the health care provider is required for payment for diabetes education.

Coverage

Priority Health covers outpatient diabetes self-management training if a member has been diagnosed with diabetes. Priority Health may cover up to 10 hours of initial training – 1 hour of individual training and 9 hours of group training. Members may also qualify for up to 2 hours of follow-up training each calendar year after the year they received their initial training.

Billing

Codes covered for all products in outpatient facility and physician office locations:

  • G0108, 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
  • Facilities billing on a UB04, use revenue code 0942 in combination with the CPT/HCPCS codes.

Training and education is payable in the following settings:

  • Hospital outpatient
  • Physician office
  • Freestanding outpatient facility

Parents, family members, or others attending the diabetic training are not reimbursed separately. Only the member diagnosed with diabetes falls within the payable benefit.

Education and training must be provided by a certified diabetic educator (CDE) employed by a provider’s office or a program that meets the national standards for diabetes patient education programs as established by the National Diabetes Advisory Board. These programs are commonly recognized by the state Department of Health or the American Diabetes Association.

Diagnosis of diabetes must be coded on the claim. Training and education may begin with an initial diagnosis of diabetes, significant change in the member’s diabetic related conditions or symptoms and/or when a new medication or therapy has been implemented for management of a member’s diabetic condition (this list isn't all inclusive):

  • Type I or II diabetes mellitus (including any manifestations)
  • Gestational diabetes
  • Neonatal diabetes mellitus

The initial visit is payable up to one hour (2 units) and subsequent or follow up sessions are payable up to nine hours (18 units) during the first year that diabetes self- management education is ongoing. In subsequent benefit years, two hours (4 units) are payable

Medical Nutrition Therapy (MNT) provided by a Registered Dietitian can be billed separately for members of most plans. (MNT doesn't necessarily have to be provided during DSMES training.)

  • 97802: Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes
  • 97803: Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes

Medical nutrition therapy for diabetes is payable for up to 6 hour (12 units) per benefit year. This may include a combination of initial therapy and follow-up or re-assessment that may occur. Note that medical nutrition therapy allowed units per benefit year is cumulative to additional conditions that are outlined in the policy for nutrition counseling, education and therapy.

Payment

Pays at the full medical benefit. If services are recommended beyond what's covered, the member may need to pay some or all of the costs.

Self-funded plans may require a copay or coinsurance instead of paying the full amount. Call the Provider Helpline to verify.

The deductible applies for HSA members.

Documentation associated with ordering educational services or medical nutrition therapy must support the medical necessity of these services. These services are subject to review of services and/or audit to validate appropriateness of services provided. Documentation must reflect group or individual therapy along with timing associated with training.