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Policy Attachment

MA00.003aa
C
MA00.003aa
Therapy and Counseling
Preventive Care Services




COUNSELING TO STOP SMOKING OR TOBACCO USE (SMOKING AND TOBACCO USE CESSATION)

COVERAGE
Counseling to stop smoking or tobacco use (smoking and tobacco use cessation) is covered as a preventive service for:
    • Individuals who use tobacco regardless of whether they exhibit signs or symptoms of tobacco-related disease
FREQUENCY
Two cessation counseling quit attempts are covered as a preventive service within a twelve month period. Each counseling attempt includes up to a maximum of four intermediate or intensive counseling sessions, up to a total of eight counseling sessions.

CPT Procedure Code​ Number(s) and Narrative(s)COUNSELING TO STOP SMOKING OR TOBACCO USE (SMOKING AND TOBACCO USE CESSATION) FOR SYMPTOMATIC INDIVIDUALS:

99406, 99407
ICD-10 Diagnosis Code Number(s) and Narrative(s) F17.210 Nicotine dependence, cigarettes, uncomplicated

F17.211 Nicotine dependence, cigarettes, in remission

F17.213 Nicotine dependence, cigarettes, with withdrawal

F17.218 Nicotine dependence, cigarettes, with other nicotine-induced disorders

F17.219 Nicotine dependence, cigarettes, with unspecified nicotine-induced disorders

F17.220 Nicotine dependence, chewing tobacco, uncomplicated

F17.221 Nicotine dependence, chewing tobacco, in remission

F17.223 Nicotine dependence, chewing tobacco, with withdrawal

F17.228 Nicotine dependence, chewing tobacco, with other nicotine-induced disorders

F17.229 Nicotine dependence, chewing tobacco, with unspecified nicotine-induced disorders

F17.290 Nicotine dependence, other tobacco product, uncomplicated

F17.291 Nicotine dependence, other tobacco product, in remission

F17.293 Nicotine dependence, other tobacco product, with withdrawal

F17.298 Nicotine dependence, other tobacco product, with other nicotine-induced disorders

F17.299 Nicotine dependence, other tobacco product, with unspecified nicotine-induced disorders

T65.211A Toxic effect of chewing tobacco, accidental (unintentional), initial encounter

T65.212A Toxic effect of chewing tobacco, intentional self-harm, initial encounter

T65.213A Toxic effect of chewing tobacco, assault, initial encounter

T65.214A Toxic effect of chewing tobacco, undetermined, initial encounter

T65.221A Toxic effect of tobacco cigarettes, accidental (unintentional), initial encounter

T65.222A Toxic effect of tobacco cigarettes, intentional self-harm, initial encounter

T65.223A Toxic effect of tobacco cigarettes, assault, initial encounter

T65.224A Toxic effect of tobacco cigarettes, undetermined, initial encounter

T65.291A Toxic effect of other tobacco and nicotine, accidental (unintentional), initial encounter

T65.292A Toxic effect of other tobacco and nicotine, intentional self-harm, initial encounter

T65.293A Toxic effect of other tobacco and nicotine, assault, initial encounter

T65.294A Toxic effect of other tobacco and nicotine, undetermined, initial encounter

Z87.891 Personal history of nicotine dependence

HCPCS Level II Code Number(s) and Narrative(s)THE FOLLOWING CODE IS NOT COVERED BECAUSE IT DOES NOT REPRESENT INTERMEDIATE OR INTENSIVE COUNSELING VISITS:

S9453 Smoking cessation classes, nonphysician provider, per session

MEDICARE DIABETES PREVENTION PROGRAM

COVERAGE
Medicare diabetes prevention program (MDPP) is covered as a preventive service for individuals enrolled in a program approved by the Centers for Disease Control and Prevention (CDC) for all sessions when all of the following criteria are met:
    • Body Mass Index (BMI) of at least 25 (23 if self-identified as Asian) on the date of the first core session
    • Any of the following blood test requirements have been met:
      • A hemoglobin A1c test with a value between 5.7% and 6.4%
      • A fasting plasma glucose of 110-125 mg/dL​
      • A 2-hour plasma glucose of 140-199 mg/dL (oral glucose tolerance test)
    • No documented history of diabetes prior to the date of the first core session (with the exception of gestational diabetes)
    • No diagnosis of end-stage renal disease (ESRD)
    • Has not previously received diabetes prevention program services.
* NOTE: Sessions will be covered when performed face-to-face or virtual (e.g. the encounter is not in person).

FREQUENCY
A maximum of 22 MDPP sessions are covered as a preventive service over a one year period. In accordance with CMS, this benefit is covered once during a member's lifetime. CMS recommends 16 weekly session during months 1 through 6 and 6 monthly sessions during months 7 through 12. 

Note: The once-per-lifetime requirement is waived for individuals who were receiving the services as of March 1, 2020 but paused or cancelled due to the COVID-19 public health emergency. 

CPT Procedure Code Number(s)​​ and Narrative(s)N/A
ICD-10 Diagnosis Code Number(s) and Narrative(s)R73.01 Impaired fasting glucose

R73.02 Impaired glucose tolerance (oral)

R73.03 Prediabetes

R73.09 Other abnormal glucose

Z68.23 Body mass index (BMI) 23.0-23.9, adult

Z68.24 Body mass index (BMI) 24.0-24.9, adult

Z68.25 Body mass index (BMI) 25.0-25.9, adult

Z68.26 Body mass index (BMI) 26.0-26.9, adult

Z68.27 Body mass index (BMI) 27.0-27.9, adult

Z68.28 Body mass index (BMI) 28.0-28.9, adult

Z68.29 Body mass index (BMI) 29.0-29.9, adult

Z68.30 Body mass index (BMI) 30.0-30.9, adult

Z68.31 Body mass index (BMI) 31.0-31.9, adult

Z68.32 Body mass index (BMI) 32.0-32.9, adult

Z68.33 Body mass index (BMI) 33.0-33.9, adult

Z68.34 Body mass index (BMI) 34.0-34.9, adult

Z68.35 Body mass index (BMI) 35.0-35.9, adult

Z68.36 Body mass index (BMI) 36.0-36.9, adult

Z68.37 Body mass index (BMI) 37.0-37.9, adult

Z68.38 Body mass index (BMI) 38.0-38.9, adult

Z68.39 Body mass index (BMI) 39.0-39.9, adult

Z68.41 Body mass index (BMI) 40.0-44.9, adult

Z68.42 Body mass index (BMI) 45.0-49.9, adult

Z68.43 Body mass index (BMI) 50.0-59.9, adult

Z68.44 Body mass index (BMI) 60.0-69.9, adult

Z68.45 Body mass index (BMI) 70 or greater, adult

Z68.52 Body mass index (BMI) pediatric, 5th percentile to less than 85th percentile for age

Z68.53 Body mass index (BMI) pediatric, 85th percentile to less than 95th percentile for age

Z68.54 Body mass index (BMI) pediatric, greater than or equal to 95th percentile for age

HCPCS Level II Code Number(s) and Narrative(s)G9880 The MDPP beneficiary achieved at least 5% weight loss (WL) from his/her baseline weight in months 1-12 of the MDPP services period under the MDPP Expanded Model (EM). This is a one-time payment available when a beneficiary first achieves at least 5% weight loss from baseline as measured by an in-person weight measurement at a core session or core maintenance session.

G9881 The MDPP beneficiary achieved at least 9% weight loss (WL) from his/her baseline weight in months 1-24 under the MDPP Expanded Model (EM). This is a one-time payment available when a beneficiary first achieves at least 9% weight loss from baseline as measured by an in-person weight measurement at a core session, core maintenance session, or ongoing maintenance session.

G9886 Behavioral counseling for diabetes prevention, in-person, group, 60 minutes

G9887 Behavioral counseling for diabetes prevention, distance learning, 60 minutes

G9888 Maintenance 5% wl from baseline weight in months 7-12

G9890 Bridge Payment: A one-time payment for the first Medicare Diabetes Prevention Program (MDPP) core session, core maintenance session, or ongoing maintenance session furnished by an MDPP supplier to an MDPP beneficiary during months 1-24 of the MDPP Expanded Model (EM) who has previously received MDPP services from a different MDPP supplier under the MDPP Expanded Model. A supplier may only rec​eive one bridge payment per MDPP beneficiary.
Modifier(s) and Narrative(s)VM Medicare diabetes prevention program (MDPP) virtual make-up session

DIABETES SELF-MANAGEMENT TRAINING (DSMT)

COVERAGE
Diabetes self-management training (DSMT) is covered as a preventive service when all of the following criteria are met:
    • The individual is diagnosed with diabetes and a qualified professional provider orders DSMT.
    • The diabetic education 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)
      • Telehealth
    • 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 American Diabetes Association, Association of Diabetes Care and Education Specialistsand Indian Health Services as meeting the National Standards for Diabetes Self- Management Education and Support established by the National Diabetes Advisory Board, with the following exception::
        • For products that allow coverage of services provided by noncontracted providers, these services may be provided according to the guidelines of the individual's Evidence of Coverage.
      • A certified diabetes educator (CDE) who is practicing in a participating provider office, with the following exception:
        • For products that allow coverage of services provided by nonparticipating providers, these services may be provided according to the guidelines of the individual's Evidence of Coverage.
FREQUENCY
The frequency of covered as a preventive service DSMT sessions is as follows:

Initial Training

The initial year for DSMT is the 12-month period following the initial date of the individual being diagnosed with diabetes. Initial training that meets ALL of the following conditions will be covered as a preventive service:
    • DSMT is furnished to an individual who has not previously received initial or follow-up training under code G0108 or G0109.
    • DSMT is furnished within a continuous 12-month period.
    • DSMT does not exceed a total of 10 hours (the 10 hours of training can be done in any combination of 1/2 hour increments).
    • With the exception of one hour of individual training, the DSMT training is usually furnished in a group setting.
    • The one hour of individual training may be used for any part of the training including insulin training.
Follow-Up Training

Follow-up training is covered as a preventive service under the following conditions:
    • No more than 2 hours individual or group training is provided per individual, per year.
    • Group training consists of 2 to 20 individuals.
    • Follow-up training for subsequent years is based on a 12-month calendar after completion of the full 10 hours of initial training.
    • Follow-up training is furnished in increments of no less than one-half hour; and
    • The professional provider treating the individual must document in the individual's medical record that the individual is a diabetic.
NOT ELIGIBLE FOR REIMBURSEMENT
DSMT must be reported using the Healthcare Common Procedure Coding System (HCPCS) codes G0108 and G0109. Providers should not report HCPCS codes S9140, S9141, S9455, S9460, or S9465 to represent DSMT. If reported, these codes will be considered not eligible for reimbursement consideration.

CPT Procedure Code Number(s) and Narrative(s)N/A
ICD-10 Diagnosis Code Number(s) and Narrative(s)N/A
HCPCS Level II Code Number(s) and Narrative(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

NOT ELIGIBLE FOR REIMBURSEMENT

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

INTENSIVE BEHAVIORAL THERAPY (IBT) FOR CARDIOVASCULAR DISEASE (ALSO REFERRED TO AS CARDIOVASCULAR DISEASE RISK REDUCTION VISIT)

COVERAGE
Intensive behavioral therapy (IBT) for cardiovascular disease is covered as a preventive service when counseling is provided by a primary care professional provider in a primary care setting.

FREQUENCY
Intensive behavioral therapy (IBT) for cardiovascular disease is covered as a preventive service once every 12 months.

CPT Procedure Code Number(s) and NarrativesN/A
ICD-10 Diagnosis Code Number(s) and Narrative(s)N/A
HCPCS Level II Code Number(s) and Narrative(s)G0446 Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes

INTENSIVE BEHAVIORAL THERAPY (IBT) FOR OBESITY

COVERAGE
Intensive behavioral therapy (IBT) for obesity is covered as a preventive service for individuals with obesity (a body mass index greater than or equal to 30 kg/m2) when counseling is provided by a primary care professional provider in a primary care setting.

FREQUENCY
A maximum of 22 intensive behavioral therapy (IBT) sessions for obesity are covered as a preventive service in a 12-month period:
    • One visit every week for the first month;
    • One visit every other week for months 2–6; and
    • One visit every month for months 7–12, if all of the following requirements are met:
      • At the six-month visit, a reassessment of obesity and a determination of the amount of weight loss must be performed.
      • To be eligible for additional face-to-face visits occurring once a month for an additional six months, the individual must have lost at least 3 kg during the first six months.
      • For individuals who do not achieve a weight loss of at least 3 kg during the first six months, a reassessment of their readiness to change and their BMI is appropriate after an additional six-month period.
CPT Procedure Code Number(s) and Narrative(s)N/A
ICD-10 Diagnosis Code Number(s) and Narrative(s)Z68.30 Body mass index (BMI) 30.0-30.9, adult

Z68.31 Body mass index (BMI) 31.0-31.9, adult

Z68.32 Body mass index (BMI) 32.0-32.9, adult

Z68.33 Body mass index (BMI) 33.0-33.9, adult

Z68.34 Body mass index (BMI) 34.0-34.9, adult

Z68.35 Body mass index (BMI) 35.0-35.9, adult

Z68.36 Body mass index (BMI) 36.0-36.9, adult

Z68.37 Body mass index (BMI) 37.0-37.9, adult

Z68.38 Body mass index (BMI) 38.0-38.9, adult

Z68.39 Body mass index (BMI) 39.0-39.9, adult

Z68.41 Body mass index (BMI) 40.0-44.9, adult

Z68.42 Body mass index (BMI) 45.0-49.9, adult

Z68.43 Body mass index (BMI) 50.0-59.9, adult

Z68.44 Body mass index (BMI) 60.0-69.9, adult

Z68.45 Body mass index (BMI) 70 or greater, adult
HCPCS Level II Code Number(s) and Narrative(s)G0447 Face-to-Face behavioral counseling for obesity, 15 minutes

G0473 Face-to-face behavioral counseling for obesity, group (2-10), 30 minutes

MEDICAL NUTRITION THERAPY

COVERAGE
Medical nutrition therapy, when provided by a registered dietician or nutrition professional, is covered as a preventive service for individuals who have been diagnosed with diabetes, renal disease, or who have received a kidney transplant within the last three years.

FREQUENCY
Three hours of one-on-one medical nutrition therapy services are covered as a preventive service in the first year. In subsequent years, two hours of medical nutrition therapy services are covered each year. Additional hours of medical nutrition therapy are covered as preventive if a provider determines there is a change in the individual's medical condition, diagnosis, or treatment regimen that requires a medical nutrition therapy change.  ​

BENEFIT APPLICATION
Additional visits for medical nutrition therapy may be available based on the member's evidence of coverage. 

CPT Procedure Code Number(s) and Narrative(s)97802, 97803, 97804
ICD-10 Diagnosis Code Number(s) and Narrative(s)See Attachment C1
HCPCS Level II Code Number(s) and Narrative(s)G0270 Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease), individual, face-to-face with the patient, each 15 minutes

G0271 Medical nutrition therapy, reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition, or treatment regimen (including additional hours needed for renal disease), group (2 or more individuals), each 30 minutes

MISCELLANEOUS

PROLONGED PREVENTIVE SERVICES
Prolonged preventive services are covered as a preventive service in the office or other outpatient setting when billed as an add-on to an applicable preventive service.

CPT Procedure Code Number(s) and Narrative(s) N/A
ICD-10 Diagnosis Code Number(s) and Narrative(s) N/A
HCPCS Level II Code Number(s) and Narrative(s) G0513 Prolonged preventive service(s) (beyond the typical service time of the primary procedure), in the office or other outpatient setting requiring direct patient contact beyond the usual service; first 30 minutes (list separately in addition to code for preventive service)

G0514 Prolonged preventive service(s) (beyond the typical service time of the primary procedure), in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes (list separately in addition to code G0513 for additional 30 minutes of preventive service)


10/01/2024
10/02/2024
N/A
Medical Policy Bulletin
Medicare Advantage
aaf9edcf-bf71-47de-a5f1-e09b853b1422
Yes