Diabetes Outpatient Self-Management Training and Education (Iowa Only)  Printer-Friendly Version
Active Policy; No Longer Scheduled For Routine Literature Review
Medical Policy: 09.01.01
Original Effective Date: February 1989
Reviewed: February 2008
Revised: May 2001
This policy applies to all products unless specific contract
limitations, exclusions or exceptions apply. Please refer to the member's coverage
manual for benefit availability. Managed care guidelines related to referral authorization,
and precertification of inpatient hospitalization, home health, home infusion and
hospice services apply.
Description:
Diabetes is a chronic illness that requires continuing medical care and education in order to prevent acute complications and reduce the risks of developing other conditions related to uncontrolled blood glucose. These other conditions may 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 Iowa must, according to State law, be certified by the Iowa Department of Public Health.
Policy:
When prescribed by a physician, the following services are covered benefits:
- Blood glucose meter and glucose strips for self-monitoring at home.
- Outpatient diabetes self-management training or education program certified by the Iowa Department of Health:
- Up to 10 hours of initial training provided within a continuous 12 month period; and
- Up to 1 hour of follow up diabetes self-management training or education annually for those who have completed the initial training.
The above services are covered benefits to diabetic individuals who meet any of the following criteria:
- A new onset of diabetes mellitus;
- Poor glycemic control as evidenced by a glycosylated hemoglobin (HbA1C) of 9.5% or more in the 90 days before attending initial training;
- A change in treatment regimen from no diabetes medication to any diabetes medication, or from oral diabetes medication to insulin;
- High risk of complications based on poor glycemic control:
- Documented acute episodes of severe hypoglycemia or acute severe hyperglycemia occurring in the past year during which the patient required hospitalization or required emergency room care; or
- High risk based on documented complications including any of the following:
- Lack of feeling in the foot;
- Foot ulcer or amputation;
- Pre-proliferative or proliferative retinopathy or prior laser treatment of the eye; or
- Kidney complications related to diabetes such as microalbuminuria or elevated creatinine.
Diabetes outpatient 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, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- Providers may use the following HCPCS codes to report diabetes outpatient education and training:
- G0108 Diabetes outpatient self management training services, individual session/30 minutes
- G0109 Diabetes outpatient self management training services, group sessions/30 minutes
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Selected References:
-
Iowa Code 2003: Section 514C.18 Diabetes Coverage.
- American Diabetes Association (2003) Third party reimbursement for diabetes care, self-management education, and supplies. Diabetes Care, 26(1),S143-S144.
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New information or technology that would be relevant for Wellmark to consider when this policy is next reviewed may be submitted to:
Wellmark Blue Cross and Blue Shield
Medical Policy Analyst
Station 304
636 Grand Ave
Des Moines, Iowa 50309
*Current Procedural Terminology © 2008 American Medical Association. All Rights Reserved.
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