1.0 HCPCS 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 calendar
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), 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.