1.0 HCPCS
PROCEDURE CODES
G0108 - Diabetes outpatient
self-management training services, individual session per 30 minutes
of training.
G0109 - Diabetes outpatient
self-management training services, group session, per individual, per
30 minutes of training.
2.0 DESCRIPTION
DSMT is an outpatient service or program that
is intended to educate beneficiaries in the successful self-management
of diabetes. The training program includes all three of the following criteria:
education about self-monitoring of blood glucose, diet, and exercise;
an insulin treatment plan developed specifically for the patient
who is insulin-dependent; and motivates patients to use the skills for
self-management. A DSMT program is accredited by the American Diabetes
Association (ADA).
3.0 POLICY
3.1 DSMT
programs as described above are covered on an outpatient basis when
the services are provided by:
3.1.1 An otherwise authorized individual
professional provider who also meets the quality standards established
by the National Standards for Diabetes Self-Management Education
Program (NSDSMEP) recognized by the ADA; or
3.1.2 An otherwise
authorized institutional TRICARE provider who is accredited by an accreditation
organization approved by the Centers for Medicare and Medicaid Services
(CMS) to provide DSMT services.
3.2 DSMT Coverage
3.2.1 Initial Training (First Year)
3.2.1.1 It is prescribed
or ordered by a physician for beneficiaries who have diabetes.
3.2.1.2 It is limited
to 10 hours.
3.2.1.3 When the
treating physician determines there is a change in medical condition,
diagnosis, or treatment that requires a change in DSMT; additional
hours are considered medically necessary and are covered.
3.2.2 Follow Up
Training (Subsequent Years)
3.2.2.1 Beneficiaries
may receive follow-up training each calendar year after the first
year in which the initial training was prescribed or ordered, even
when there is no documentation the initial training has been received.
3.2.2.2 Such follow-up
training includes a change in DSMT due to a change in medical condition, diagnosis,
or treatment as determined by the treating physician.
3.2.2.3 All follow-up
training is limited to two hours per year.
3.3 The following
medical conditions, as well as any other medical condition in which
DSMT is medically necessary, would be eligible for coverage for
training services.
3.3.1 New onset diabetes.
3.3.2 Poor glycemic control as evidenced
by a glycosylated hemoglobin (HbA1C) of 7.0 or more in the 90 days
before attending the training.
3.3.3 A change in the treatment
regimen from no diabetes medications to any diabetes medication,
or from oral diabetes medication to insulin.
3.3.4 High risk
for complications based on poor glycemic control; documented episodes
of severe hypoglycemia or acute severe hypoglycemia occurring in
the past year during which the beneficiary needed third party assistance
for either emergency room visits or hospitalization.
3.3.5 High risk
based on at least one of the following documented complications:
3.3.5.1 Lack of
feeling in the foot or other foot complications such as foot ulcer
or amputation.
3.3.5.2 Pre-proliferative
or proliferative retinopathy or prior laser treatment of the eye.
3.3.5.3 Kidney
complications related to diabetes, such as macroalbuminuria or elevated
creatinine.
3.4 Benefits are cost-shared only
for services related to the beneficiary. Therefore, we would encourage
caregivers to attend the training with the beneficiary.
3.5 Payment for
DSMT
3.5.1 Individual providers who furnish services as
part of a DSMT program and who provide care under the supervision
of a physician, e.g., Registered Dietitians (RDs), nutritionists,
Registered Nurses (RNs), etc., may not bill separately for their
services.
3.5.2 Only those authorized TRICARE institutional
providers and those authorized TRICARE individual providers who
are able to practice independently, whose DSMT program meets the provisions
in
paragraph 3.1 may
bill and receive payment for the entire DSMT program.
3.5.3 Healthcare
Common Procedure Coding System (HCPCS) codes G0108 and G0109 identify covered
DSMT program services. When billing for these codes the provider
must provide a copy of his/her accreditation certificate. Pricing
of these Level II HCPCS codes is under the allowable charge methodology
per the TRICARE Reimbursement Manual (TRM). Once sufficient data
is collected, the contractors, as part of the CHAMPUS Maximum Allowable
Charge (CMAC) annual update, will be provided pricing information
for these codes.