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.