MP-08 Diabetes Self-Management Education and Support (DSMES) Form

Diabetes Self‐Management Education and Support (DSMES) Program

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Medical Policy
Current Effective Date: 5/8/2018
Original Effective Date: 01/01/2015
Next Review/Revision Date: 5/8/2019
Plans: QUEST Integration (Medicaid), AlohaCare Advantage Plus Special Needs Plan (SNP Medicare)

I. Definition

Diabetes Self‐Management Education and Support (DSMES) is a collaborative and ongoing process of assisting diabetic patients in implementing and sustaining the knowledge, skill, and ability necessary in promoting self‐management and self‐care. This process involves the person with diabetes and a diabetes educator(s). It aims to help diabetic members realize optimal health status, to achieve improved clinical outcomes and quality of life, and to reduce the potential long‐term costs imposed by uncontrolled diabetes.

The DSMES program is a consecutive 12‐month program. It is covered once per lifetime. An educational unit
is equal to 30 minutes.

II. Criteria
AlohaCare will consider the coverage of DSMES programs for QUEST and Medicare members as medically necessary when ALL of the following criteria are met:
A. The DSMES programs must be

1. Accredited by the American Diabetes Association (ADA) or the American Association of Diabetes Educators (AADE) as meeting the National Standards for Diabetes Self‐Management
   Education and Support
   (http://www.cardinalhealth.com/content/dam/corp/web/documents/data‐ sheet/cardinalhealth‐national‐dsme‐standards.pdf ).
2. Ordered by a physician, a physician assistant, an advanced practice registered nurse (ARPN), clinical psychologist, clinical social worker, clinical nurse specialist, or a registered dietitian or nutrition professional.
3. Performed by a licensed, certified, or registered dietitian or nutrition professional who is an ADA or AADE certified diabetes educator.
   B. AlohaCare covers the DSMES programs for Medicaid members diagnosed with pre‐diabetes or
   diabetes, according to ADA’s guidelines.
4. Pre‐diabetes mellitus
   • At an Hemoglobin A1c (HbA1C) of 5.7% ‐ 6.4%; or

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Medical Policy
• At a Fasting Plasma Glucose (FPG) of 100 mg/dl – 125 mg/dl (5.6 mmol/L–6.9 mmol/L); or
• At an Oral Glucose Tolerance Test (OGTT) 2 hour blood glucose of 140 mg/dl – 199 mg/dl (7.8 mmol/L–11.0 mmol/L)

2. Diabetes mellitus
   • HbA1C ≥ 6.5%; or
   • FPG ≥ 126 mg/dl (7.0 mmol/L); or
   • OGTT 2 hour blood glucose ≥ 200 mg/dl (11.1 mmol/L); or
   • Random blood glucose ≥ 200 mg/dl (11.1 mmol/L)
   C. AlohaCare covers the DSMES programs for SNP Medicare members diagnosed with diabetes.
   • FPG ≥ 126 mg/dl on two different occasions
   • OGTT 2 hour blood glucose ≥ 200 mg/dl on two different occasions
   • Random blood glucose ≥ 200 mg/dl with symptoms of uncontrolled diabetes

   III. Guidelines

   A. For Medicaid members, prior authorization (PA) is not required. Each of the following disease levels is covered for a duration of 12‐month. One unit is equal to 30 minute training. The training can be done in any combination of 30 minute increments.

3. Initial visits
   a. Pre‐diabetes: 4 units (2 hours)
   b. Diabetes: 10 units (5 hours)
   • Additional 10 units (5 hours), due to o Uncontrolled blood glucose level; or
   o Use of an insulin pump if the pump is not ordered during the initial DSMES
   program; or
   o Inability to become appropriately familiarize with the DSMES program in the initial year due to other comorbidities or any other inability during the initial visits.
4. Follow‐up visits
   Follow‐up visits will be covered each year, beginning with the calendar year following the year in which the member completed the DSMES program, if one of the criteria listed below has been met:
   • The member has uncontrolled blood glucose level.
   • The member needs instruction on the use of an insulin pump if the pump is not ordered
   during the initial DSMES program.

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Medical Policy
• The member is unable to become appropriately and sufficiently familiarize with the initial DSMES program in the previous year due to other comorbidities or any other inability during the initial visits.
a. Pre‐diabetes: 1 unit (30 minutes)
b. Diabetes: 4 units (2 hours)

3. Medical record, which includes the diagnosis, assessment of education needs, training goals, and individual or group sessions, must be provided along with the PA request.

   B. For SNP Medicare members, PA is not required.

4. Initial 20 units (10 hours) of visits within a continuous 12‐month period. One unit is equal to 30 minute training.
   a. One hour of individual training and nine hours of group training consisting of 2 to 20 individuals who do not all need be SNP Medicare beneficiaries.
   b. Individual basis training is covered if any of the flowing conditions are met:
   • No group session is available within two months of the date the training is ordered.
   • The medical records document that the member has special needs resulting from conditions, such as severe vision, hearing, or language limitations that will hinder effective participation in a group training session.
   • Need for additional one on one session(s) for insulin training
   • The need for individual training must be identified and documented by the ordering provider.
5. 4 units (2 hours) of follow‐up visits each year, beginning with the calendar year following the year in which the member completed the DSMES program.

6. Medical record, which includes the diagnosis, assessment of education needs, training goals, and individual or group sessions, must be provided along with the PA request.
   (For more information regarding Medicare coverage guidelines for DSMES program, please see Medicare website at http://www.cms.gov/medicare‐coverage‐database/details/ncd‐details.aspx?NCDId=251&bc=AgAAQAAAAAAA&ncdver=1 )

   Note: AlohaCare recommends members to pursue DSMES programs which are certified by ADA or AADE and are in the network with AlohaCare.

   IV. Limitations

   A. Self‐referral to a DSMES program is not covered.
   B. The DSMES will not be reimbursed if the training is provided on the same day of the services of medical nutrition therapy.

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C. The following providers are not eligible of billing for DSMES:
• Certified diabetes educator
• End‐stage renal facility
• Hospice service
• Hospital inpatient service
• Nurse, not a specialist
• Nursing home
• Pharmacist
D. Rural Health Clinics (RHC) Federal (FQHC) can only be reimbursed for DSMES when provided for individual training on a separate day of another medical service.

V. Coding Information

The following medical codes are relevant codes for diagnosis and procedures for Diabetes Self‐Management Education and Supports. All the medical codes listed in this policy are for informational purposes only and not for benefit coverage or provider reimbursement.
ICD‐10
Description
E11.9
Type 2 diabetes mellitus without complications
E10.9
Type 1 diabetes mellitus without complications
E11.65
Type 2 diabetes mellitus with hyperglycemia
E10.65
Type 1 diabetes mellitus with hyperglycemia
E11.29
Type 2 diabetes mellitus with other diabetic kidney complication
R73.09
Other abnormal glucose
HCPCS
Description
PA
G0108
Diabetes outpatient self‐management training services, individual, per 30 minutes of training.
No
G0109
Diabetes self‐management training services, group session (two or more), per 30 minutes.
No

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References/Resources

Document Name
Effective Date Source/Link

Diagnosing Diabetes and
11/21/2016
American Diabetes Association

Learning About Prediabetes
http://www.diabetes.org/diabetes‐ basics/diagnosis/?loc=db‐slabnav Section §410.141‐Outpatient
10/1/2016
42 CFR 410.140 ‐ 410.146
diabetes self‐management
https://www.govinfo.gov/app/details/CFR‐2016training
title42‐ vol2/CFR‐2016‐title42‐vol2‐sec410‐ 141/summary

Diabetes Management
2014
National Diabetes Education Initiative. American

Guidelines
Diabetes Association.
http://www.ndei.org/ADA‐2014‐guidelines‐ diabetesdiagnosis‐A1C‐testing.aspx

Diabetes Management
2014
National Diabetes Education Initiative. American

Guidelines
Diabetes Association.
http://www.ndei.org/ADA‐2014‐guidelines‐ diabetesdiagnosis‐A1C‐testing.aspx

National Standards for
09/20/2012
Linda Haas, Medinda Maryniuk, et al. American

Diabetes Self‐Management
Association of Diabetes Educators.

Education and Support
http://www.diabeteseducator.org/export/sites/aade/

_resources/pdf/general/2012NationalStandards.pdf Diabetes‐Related Services Fact
05/2011

Medicare Learning Network

sheet
http://www.cms.gov/Outreach‐and‐ Education/Medicare‐Learning‐Network‐ MLN/MLNProducts/downloads/DiabetesSvcs.pdf
Guidelines for the Practice of
2009 American Association of Diabetes Educators.

Diabetes Education
http://www.ndei.org/ADA‐2014‐guidelines‐diabetes‐ diagnosis‐A1C‐testing.aspx
Guidelines for Payment of 07/02/2007 https://www.cms.gov/Outreach‐andDiabetes Self‐ Management
Education/Medicare‐Learning‐Network‐

Training (DSMT)
MLN/MLNMattersArticles/downloads/MM5433.pdf

Medicare Benefit Policy
05/28/2004
CMS Manual System

Manual for Diabetes Self‐ http://www.cms.gov/Regulations‐and‐

Management Training Services
Guidance/Guidance/Transmittals/downloads/R13BP.p df

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What Is Diabetes Educator
N/A
American Association of Diabetes Educators.
http://www.diabeteseducator.org/DiabetesEducation/ Definitions.html

Accredited Programs
N/A
AADE
http://www.diabeteseducator.org/ProfessionalResour ces/accred/Programs.html#Hawaii ADA
http://professional.diabetes.org/erp_list.aspx

Review/Revision History
9/1/2017, reviewed the policy.
5/8/2018, prior authorization was not removed for DSMES services.
5/8/2019, Retired