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TRICARE Policy Manual 6010.60-M, April 1, 2015
Other Services
Chapter 8
Section 8.1
Diabetes Self-Management Training (DSMT) Services
Issue Date:  
Authority:  32 CFR 199.4 and 32 CFR 199.6
Revision:  
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.
4.0  EFFECTIVE DATE
July 1, 1998.
- END -

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