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Medical Policy: 09.01.02
Original Effective Date: February 1989
Reviewed: November 2011
Revised: August 2001
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Diabetes is a chronic illness that requires continuing medical care and education in order to prevent acute complications and reduce the risk of developing other conditions related to uncontrolled blood glucose. These other conditions include retinopathy, nephropathy, neuropathy, and cardiovascular disease.
Outpatient diabetes training is a program that educates patients in the successful self-management of diabetes. The program includes education about self-monitoring of blood glucose and diet and exercise, as well as an insulin treatment plan for those who are insulin-dependent. Diabetes education programs provided in South Dakota, according to State law, must be recognized by the American Diabetes Association (ADA) or the South Dakota Department of Health.
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Prior Approval:
Not applicable
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Policy:
Outpatient diabetes self-management training and education services are covered benefits available to members who meet one of the following criteria, as defined by the South Dakota State Code:
- Those who are newly diagnosed with diabetes mellitus or gestational diabetes;
- Those patients with diabetes who have not previously received diabetes education;
- Those who demonstrate poor glycemic control as evidenced by glycated hemoglobin level more than 2% above the upper limit of normal for the assay used;
- Those who have a physician's order for a change in treatment regimen;
- Those with documented episodes of acute, severe hypoglycemia or hyperglycemia occurring in the past year requiring hospital admission or care in the hospital emergency department; or
- Those at high risk because of the presence of extremity, renal, or cardiac complications, or diabetic retinopathy.
An outpatient diabetes self-management education program provided in South Dakota is limited to the following:
- Up to 10 hours of initial education during the individual's lifetime; and
- Up to 2 hours a year of follow-up education.
Diabetes self-management training is not a covered benefit if the above criteria are not met.
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- Providers should use the following HCPCS codes to report outpatient diabetes education and training:
- G0108 Diabetes outpatient self-management training services, individual sessions/30 minutes
- G0109 Diabetes outpatient self-management training services, group sessions/30 minutes
- S9140 Diabetic management program, follow up visit to a non-MD provider
- S9141 Diabetic management program, follow up visit to MD provider
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Selected References:
- South Dakota State Code, Chapter 67:16:46.
- American Diabetes Association. (2003). Third party reimbursement for diabetes care, self-management education, and supplies. Diabetes Care, 26(1),S143-S144.
- American Diabetes Association. Third-Party Reimbursement for Diabetes Care, Self-Management Education, and Supplies. Diabetes Care January 2009 32:S85-S86.
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Policy History:
Date Reason Action
October 2010 Annual review Policy renewed
November 2011 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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