LCD/NCD Portal

L29133

 

DIABETES OUTPATIENT SELF-MANAGEMENT TRAINING

 

03/30/2009

 

Indications and Limitations of Coverage and/or Medical Necessity

 

Medical Eligibility for Coverage and Definition of Diabetes

• Diabetes is diabetes mellitus, a condition of abnormal glucose metabolism diagnosed using the following criteria:

o A fasting blood sugar (8-14 hours) greater than or equal to 126mg/dL on two different occasions.

o A 2 hour post-glucose challenge greater than or equal to 200mg/dL on two different occasions.

o A random glucose test over 200mg/dL for a person with symptoms of uncontrolled diabetes.

• Diabetes mellitus is classified according to two syndromes: Type 1 diabetes and Type 2 diabetes.

o Type 1 diabetes is characterized by beta cell destruction, usually leading to absolute insulin deficiency. It has two forms:

 Immune-Mediated Diabetes Mellitus.

 Idiopathic Diabetes Mellitus. (Type 1 diabetes is usually immune-mediated.)

o Type 2 diabetes is a term for individuals who have insulin resistance and usually have relative (rather than absolute) insulin deficiency.

• Since diabetes is a chronic illness, the patient requires continual medical care and education in order to prevent acute complications and reduce the risk of long-term medical problems.

o A critical element for the successful treatment of all patients with diabetes is participation in a comprehensive self-management care and education program.

o Ongoing support, maintenance, and modifications in treatment regimens and lifestyle changes all require continued patient and caregiver participation.

• A diabetes outpatient self-management training (DSMT) service is a program that educates beneficiaries in the successful self-management of diabetes.

o 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.

 It motivates patients to use the skills for self-management.

• Medicare coverage of diabetes outpatient self-management training (DSMT) was based on Section 80-2 of the Coverage Issues Manual prior to July 1, 1998.

o Effective for services performed on or after July 1, 1998 until February 26, 2001, coverage of diabetic training was based on the criteria identified in Program Memorandums AB99-46, AB99-30, AB98-36, and AB98-51.

o Effective for services performed on or after February 27, 2001 expanded coverage of diabetes outpatient self-management training is covered when the following criteria are met.

 

General Conditions of Coverage

 

• The training must be ordered by the physician or qualified nonphysician practitioner treating the beneficiary’s diabetes.

o The order must be part of a comprehensive plan of care established by the physician or qualified nonphysician practitioner and describe the training that the referring physician or qualified non-physician practitioner is ordering and/or any special concerns such as the need for general training, or insulin-dependence.

• The plan of care must be maintained in the medical record of the ordering provider and document the need for training on an individual basis when group is typically covered.

• The order must include a statement signed by the physician that the service is needed as well as the following:

o The number of initial or follow-up hours ordered. (the physician can order less than 10 hours of initial training).

o The topics to be covered in training. (initial training hours can be used for the full initial training program or specific areas such as nutrition or insulin training).

o A determination that the beneficiary should receive individual or group training.

• The provider of the service must maintain documentation in the file that includes the original order from the physician and any special conditions noted by the physician.

• Any change in the training order/referral must be signed by the physician or qualified nonphysician practitioner treating the beneficiary and maintained in the beneficiary’s file in the DSMT’s program records.

• Note: All entities billing for DSMT under the fee-for-service payment system or other payment systems, facilities, federally qualified health centers (FQHCs), End-Stage Renal Disease (ESRD), rural health clinics (RHCs) or managed care organizations must meet all national coverage requirements.

• When a beneficiary has not previously received initial or follow-up training under HCPCS G0108 or G0109 meeting the quality standards of this section, they are eligible to receive 10 hours of initial training within a continuous 12-month period.

o Nine hours of initial training are usually provided in a group setting consisting of 2 to 20 individuals unless the ordering physician or nonphysician practitioner certified that a special condition exists that makes it impossible for the beneficiary to attend a group training session.

o Those conditions include but are not limited to:

 No group session is available within 2 months of the date the training is ordered.

 The beneficiary has special needs resulting from problems with hearing, vision, or language limitations or other special conditions identified by the treating physician or nonphysician practitioner.

 Additional insulin instruction is needed.

o The need for individual training must be identified by the physician or non-physician practitioner in the referral.

• The one hour of individual training may be used for any part of the training including insulin training.

o The 10 hours of initial training may be provided in any combination of half-hour increments within the 12-month period and less than 10 hours of initial training may be used in the 12-month period.

• Two hours of follow-up training is covered each year starting with the calendar year following the year in which the beneficiary completes the initial training or they may receive follow-up training when ordered even if Medicare does not have documentation that initial training has been received.

o In that instance, contractors shall not deny the follow-up service even though there is no initial training recorded.

o The 2 hours of training may be given in any combination of half-hour increments within each calendar year on either an individual or group basis.

o The ordering physician or qualified nonphysician practitioner treating the beneficiary must document in the beneficiary’s medical record that the beneficiary is a diabetic.

 

Quality Standards

• The outpatient diabetes self-management training program must be accredited as meeting approved quality standards, except during the first 18-months after February 27, 2001.

• CMS will accept recognition of the American Diabetes Association (ADA) as meeting the National Standards for Diabetes Self-Management Training Programs as published in Diabetes Care, volume 23, number 5.

o Programs without ADA recognition or accreditation by the CMS-approved national accreditation organization are not covered after February 27, 2001.

• In addition to the ADA, effective January 1, 2004, the Indian Health Service (IHS) will be recognized as a CMS-approved national accreditation organization.

• Effective March 30, 2009, the American Association of Diabetes Educators (AADE) is recognized as a national accreditation organization for accrediting entities to furnish outpatient diabetes self-management training (DSMT).

 

CPT/HCPCS Codes

 

 

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

 

 

ICD-9 Codes that Support Medical Necessity

 

 

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

 

 

Documentation Requirements

• In order for diabetic self-management training sessions to be covered by Medicare, documentation must be available to support that the educational program is certified by the American Diabetes Association, the Indian Health Service, or the American Association of Diabetes Educators, as evidenced by the Education Recognition Program (ECP) certificate.

• In addition to the above requirement, the following documentation must be maintained in the patient’s medical record:

o The treating physician or qualified nonphysician practitioner must order the diabetic training and describe the training needed for each beneficiary including any special concerns/conditions or rationale for providing individual training versus group training.

 This order, which includes a statement indicating that the service is needed, must be signed by the ordering physician or qualified nonphysician practitioner and included as part of a comprehensive plan of care.

 This plan of care must be maintained in the ordering provider’s medical record.

 Documentation that the beneficiary is diabetic is also to be maintained in the beneficiary’s medical record.

o The provider of the diabetic training must maintain in the beneficiary’s medical record the original order from the physician/nonphysician practitioner and any special conditions noted by the ordering provider.

 Any change in the training order/referral must be signed by the physician or qualified nonphysician practitioner treating the beneficiary and maintained in the performing provider’s file.

o An individualized assessment including

 Relevant medical history.

 Cultural influences.

 Health beliefs and attitudes.

 Diabetes knowledge.

 Self-management skills and behaviors.

 Readiness to learn.

 Cognitive ability.

 Physical limitations.

 Family support.

 Financial status.

o An individualized mutually agreed upon education plan established by the team (patient, physician, and health care team members) based on the individualized assessment, including but not limited to the problems to be addressed, the educational objectives, and educational modality(ies) used to meet the objectives.

o A periodic individualized reassessment between the beneficiary and instructor(s) that indicates the progress toward the goal(s).

o Attendance sheets documenting that the beneficiary was present during each training session must be part of the beneficiary’s file maintained by the provider of the service.

 

Utilization Guidelines

• Initial training encompasses up to 10 hours of training within a continuous 12-month period.

o Nine of these hours are usually provided in a group setting unless a special condition exists as identified in the “Indications and Limitations of Coverage and/or Medical Necessity” section of this policy.

• Follow-up training of up to 2 hours training is covered each year starting with the calendar year following the year in which the beneficiary completes the initial training (e.g., beneficiary completes initial training in November 2003 therefore the beneficiary is entitled to 2 hours of follow-up training beginning in January of 2004).

o The beneficiary may also receive follow-up training when ordered even if Medicare does not have documentation that initial training has been received.

 

Sources of Information and Basis for Decision

 

Diabetes Medical Practice Guidelines. (1998). The Journal of the Florida Medical Association, 85 (2), 39-62.

 

FCSO LCD 29133 Diabetes Outpatient Self-Management Training, 03/30/2009. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

National standards for diabetes self-management education. (2000). Diabetes Care, 23 (5), 682-689.

 

Thomas, C. L. (Ed.). (1993). Taber’s Cyclopedic Medical Dictionary (17th ed.). Philadelphia: F. A. Davis.

 

 

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

 

© Automated Clinical Guidelines, LLC 2009-2014

 

CMS LCD L29133 Diabetes Outpatient Self-Management Training