L29133-LCD

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Local Coverage Determination (LCD) for Diabetes Outpatient Self- Management Training (L29133)

Contractor Information

Contractor Name

First Coast Service Options, Inc. opens in new window

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L29133

LCD Title

Diabetes Outpatient Self-Management Training

Contractor's Determination Number G0108

Primary Geographic Jurisdiction opens in new window Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 02/02/2009 Original Determination Ending Date

Revision Effective Date

For services performed on or after 03/30/2009 Revision Ending Date

CMS National Coverage Policy

Program Memorandum B-03-043 (Change Request 2157, dated 05/23/2003) Program Memorandum B-01-40 (Change Request 1455, dated 06/15/2001) Program Memorandum AB-02-151 (Change Request 2373, dated 10/25/2002) Transmittal 1895 (Change Request 2793, dated 08/01/2003)

Program Memorandum 13 (Change Request 3185, dated 05/28/2004)

CMS Manual System, Pub. 100-04, Medicare Claims Processing, Chapter 9, Section 181 and Chapter 18, Section 120

CMS Manual System, Pub. 100-02, Medicare Benefit Policy, Chapter 15, Section 300, Section 300.2 Change Request 6510 (Transmittal 109), dated 08/07/2009

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:

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

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

• 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. Type 1 diabetes is characterized by beta cell destruction, usually leading to absolute insulin deficiency. It has two forms: Immune- Mediated Diabetes Mellitus and Idiopathic Diabetes Mellitus. Type 1 diabetes is usually immune-mediated. 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. A critical element for the successful treatment of all patients with diabetes is participation in a comprehensive self-management care and education program. Ongoing support, maintenance, and modifications in treatment regimes 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. 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, and 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. 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. 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. 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:

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

- 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); and

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

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

999x Not Applicable

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

99999 Not Applicable

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 - 250.93 opens DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE II OR UNSPECIFIED

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TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH UNSPECIFIED COMPLICATION,

TYPE I [JUVENILE TYPE], UNCONTROLLED

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity N/A

XX000 Not Applicable

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations 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:

• 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.

• 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.

• 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, and financial status.

• 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.

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

• 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.

Appendices

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

Advisory Committee Meeting Notes This Local Coverage Determination (LCD) does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this LCD was

developed in cooperation with advisory groups, which includes representatives from numerous societies.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 10/01/2009

Revision History Number 1

Revision History Explanation Revision Number:1 Start Date of Comment Period:N/A

Start Date of Notice Period:10/01/2009 Revised Effective Date: 03/30/2009

LCR B2009-092

September 2009 Update

Explanation of Revision: Change Request 6510, Transmittal 109, dated August 7, 2009, instructed contractors to recognize the American Association of Diabetes Educators (AADE) as a national accreditation organization for accrediting entities to furnish outpatient diabetes self-management training (DSMT). The effective date of this revision is for claims processed on or after 09/08/2009 for dates of service on or after 03/30/2009.

Revision Number:Original

Start Date of Comment Period:N/A Start Date of Notice Period:12/04/2008 Revised Effective Date:02/02/2009

LCR B2009-

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the carrier predecessors of First Coast Service Options, Inc. (Triple S and FCSO).

For Florida (00590) this LCD (L29133) replaces LCD L6148 as the policy in notice. This document (L29133) is effective on 02/02/2009.

Reason for Change