Medical Policy: 09.01.02
Original Effective Date: February 1989
Reviewed: May 2016
Revised: June 2015
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.
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 education and self - management training is a formalized, comprehensive outpatient program that teaches individuals who have been diagnosed with diabetes about their diagnosis and its treatment. Components of such programs typically include, but are not limited to the following: blood glucose self-monitoring; dietary requirements; exercise and its role in the management of diabetes; if necessary, instruction on the self-administration of pharmaceutical agents for the treatment of diabetes as well as an insulin treatment plan.
Diabetes education programs provided in South Dakota, according to State law, must be provided by a physician, nurse, dietician, pharmacist, or other licensed health care provider who satisfies the current academic eligibility requirements of the National Certification Board for Diabetic Educators and has completed a course in diabetes education and training or has been certified as a diabetes educator; and the training and education is based upon a diabetes program recognized by the American Diabetes Association or a diabetes program with a curriculum approved by the American Diabetes Association (ADA) or the South Dakota Department of Health.
Outpatient diabetes self-management training and education services are considered medically necessary for members who meet one of the following criteria, as defined by the South Dakota State Code:
- Persons who are newly diagnosed with diabetes mellitus or have received no prior diabetes education;
- Persons who require a change in current therapy;
- Persons who have a co-morbid condition such as heart disease or renal failure; or
- Persons whose diabetes condition is unstable
An outpatient diabetes self-management training and education program provided in South Dakota is limited to the following:
- No more than two comprehensive education programs per lifetime; and
- Up to eight follow up visits per year need to be covered.
Coverage is limited to the closest available qualified education program that provides the necessary management training to accomplish the prescribed treatment.
Diabetes self-management training is considered not medically necessary if the above criteria are not met.
Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or diagnosis 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
- S9455 Diabetic management program, group session
- S9460 Diabetic management program, nurse visit
- S9465 Diabetic management program, dietician visit
- 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.
- South Dakota State Code 58-18-83 amendment in 200 regarding diabetes self management training and education
- Funnell MM, Brown TL, Childs BP, et al. National standards for diabetes self-management education. Diabetes CareExternal Site (serial online). 2009;32:S87-S94. [Diabetes Care Web site].
May 2016 - Annual Review, Policy Renewed
June 2015 - Annual Review, Policy Revised
July 2014 - Annual Review, Policy Renewed
September 2013 - Annual Review, Policy Revised
October 2012 - Annual Review, Policy Renewed
November 2011 - Annual Review, Policy Renewed
October 2010 - Annual Review, Policy Renewed
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 © 2012 American Medical Association. All Rights Reserved.