Diabetes Outpatient Self-Management Training and Education (South Dakota only)  Printer-Friendly Version
Active Policy; No Longer Scheduled For Routine Literature Review
Medical Policy: 09.01.02
Original Effective Date: February 1989
Reviewed: February 2008
Revised: August 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 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.
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 diabetic patients 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, 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.
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New information or technology that would be relevant for Wellmark to review when this policy is next updated 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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