Notification



Notification Issue Date:



Claim Payment Policy


Title:Outpatient Diabetes Education and Self-Management Training

Policy #:12.05.01i

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.

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.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract. State mandates do not automatically apply to self-funded groups; therefore, individual group benefits must be verified.

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 (e.g., 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 professional 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 professional provider office, with the following exception:
      • For Medicare Advantage and NJ products that allow coverage of services provided by nonparticipating professional 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, professional providers (i.e., 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.


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 professional 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.
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 August 26, 2013.


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 August 26, 2013.

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 August 26, 2013.

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 August 26, 2013.

National Certification Board for Diabetes Educators (NCBDE). Eligibility requirements. [NCBDE Web site]. Available at: http://www.ncbde.org/certification_info/eligibility-requirements. Accessed August 26, 2013.

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 August 26, 2013.

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 August 26, 2013.

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 August 26, 2013.

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 August 26, 2013.

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 August 26, 2013.

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 August 26, 2013.

US Department of Health & Human Services. Your Medicare Coverage.Diabetic supplies & services. [Medicare.gov Web site]. Available at: http://www.medicare.gov/coverage/diabetes-supplies-and-services.html. Accessed August 26, 2013.

US Department of Health & Human Services. Your Medicare Coverage.Diabetes self-management training. [Medicare.gov Web site]. Available at: http://www.medicare.gov/coverage/diabetes-self-mgmt-training.html. Accessed August 26, 2013.




Coding

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.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

98960, 98961, 98962, 99078


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Diagnosis Code Number(s)

See Attachments A, B and C


HCPCS Level II Code Number(s)

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

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 Code Number(s)

942: Education/Training

Coding and Billing Requirements


Cross References

Attachment A: Outpatient Diabetes Education and Self-Management Training
Description: ICD-10 CM Codes Eligible to be Reported for Outpatient Diabetes Education and Self-Management Training (E08.00- E10.3491)

Attachment B: Outpatient Diabetes Education and Self-Management Training
Description: ICD-10 CM Codes Eligible to be Reported for Outpatient Diabetes Education and Self-Management Training (E10.3492- E13.37X2), Continued

Attachment C: Outpatient Diabetes Education and Self-Management Training
Description: ICD-10 CM Codes Eligible to be Reported for Outpatient Diabetes Education and Self-Management Training (E13.37X3- P70.2), Continued



Policy History

Effective 10/05/2017 this policy has been updated to the new policy template
format.
Version Effective Date: 10/01/2017
Version Issued Date: 09/29/2017
Version Reissued Date: N/A

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2017 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.