CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy | Diabetes Self-Management Education Mandate

Defines Rhode Island-mandated coverage for diabetes self-management education (DSMES) and correct billing for Commercial products; documents covered CPT/G, S codes, session formats, providers, and limits on coverage as per RIGL 27-20-30. Applicable to Commercial products; self-funded groups may opt out.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy | Diabetes Self-Management Education Mandate

Policy CodePolicy N/A

Change Typeclarified

Effective DateApr 1, 1999

Next Review Date

Key ActionDocument physician diagnosis and medical necessity reason and referrals when services are provided by non-physician certified providers.

SourceLink

POLICY UPDATE CHANGES

Policy documents the Rhode Island statutory mandate RIGL 27-20-30 requiring coverage of DSMES and correct billing.

CommercialProduct Applicability

G0108/G0109Key covered professional codes

S9140/S9455/S9460/S9465Key covered institutional codes

Not requiredPrior Authorization

Overview: This policy implements the Rhode Island statutory mandate RIGL 27-20-30 requiring coverage for diabetes self-management education (DSMES), diabetes equipment and supplies, and medical nutrition therapy. It applies to Commercial products only and documents covered CPT/G and institutional S codes, session formats, provider types, and limits on coverage as specified by the statute. Note: self-funded groups may opt out and therefore may not follow the state mandate.

Key scope points: Defines Rhode Island-mandated coverage for DSMES and correct billing for Commercial products; documents covered professional codes (G0108/G0109) and institutional S codes (S9140/S9455/S9460/S9465); describes permitted session formats (group sessions, individual, home visits); and limits coverage to medically necessary visits at diagnosis, for significant change, or for refresher training.

Surface compact policy metadata

Product ApplicabilityCommercial only (self-funded groups may opt out)

Coverage StanceCovered with criteria per Rhode Island mandate RIGL 27-20-30

Prior AuthorizationPrior authorization review is not required

Effective Date1999-04-01

Last Review2018-08-21

Medical-Necessity Criteria

Coverage Conditions for Diabetes Self-Management Education

Covered when ALL of the following are met:

ALL of the following

Member coverage: Member is covered under a Rhode Island individual or group health insurance contract, plan, or policy that provides medical coverage including physician office services or major medical/comprehensive coverage
Medical necessity and prescription: Diabetes self-management education is medically necessary and prescribed by a physician
Medically necessary visits are limited to: upon diagnosis of diabetes; when a physician diagnoses a significant change in the patient's symptoms/conditions necessitating changes in self-management; or when reeducation/refresher training is necessary
Provider types and settings: Education may be provided by a physician or, upon physician referral, an appropriately licensed and certified health care provider
May be conducted in group settings or include home visits when medically necessary
Benefit variability and self-funded groups: Benefits vary by group/contract; refer to Benefit Booklet/Evidence of Coverage/Subscriber Agreement
Self-funded groups may not follow state mandates

Provider/Service Delivery Requirements

Services are covered when provided as specified:

ALL of the following

Pre-assessment evaluation: one-hour evaluation by a certified diabetes educator to develop education program including assessment of medical condition, demographics, knowledge/skills, and meal planning
Group sessions: typical program consists of seven, two-hour sessions by a state-certified diabetes educator on diabetic care topics
Individual sessions: when one-on-one education required, provided by a certified diabetes educator; typically five one-hour meetings needed

Definitions:

Medically necessary visits: Visits upon diagnosis of diabetes; where a physician diagnoses a significant change in the patient's symptoms or conditions necessitating changes in the patient's self-management; or where reeducation or refresher training is necessary.

Certified diabetes educator: A state-certified diabetes educator or appropriately licensed and certified health care provider as referenced by the statute; may include a Certified Outpatient Diabetes Educator (CDOE) or a Registered Dietitian/Nutritionist.

Coding

Covered professional G codes (physician, CDOE, RDN)CPTCovered

G0108	Diabetes outpatient self-management training services, individual, per 30 minutes
G0109	Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes

Covered institutional S codes (institutional providers only)HCPCSCovered

S9140	Diabetic management program, follow-up visit to non-MD provider
S9455	Diabetic management program; group session
S9460	Diabetic management program; nurse visit
S9465	Diabetic management program; dietitian visit

S code not separately reimbursed if E&M billed (professional)HCPCSNot Covered

S9141

Diabetic management program, follow-up visit to MD provider (not separately reimbursed when an appropriate E&M service code is filed)

Actions for Providers / Billing

Documentation Required

Medical necessity documentation

Document the physician diagnosis and the medical necessity reason for DSMES services. Include the specific reason for the visit: initial diagnosis of diabetes, a significant change in symptoms/condition requiring changes in self-management, or the need for reeducation/refresher training. If education is delivered by a non-physician certified provider, document the physician referral that authorizes that provider to deliver the education.

Initial diagnosis of diabetes
Significant change in symptoms/condition requiring management change
Need for reeducation or refresher training

Billing Rule

Use appropriate E&M or DSMES codes

When diabetes education/management is performed by a physician, file an appropriate E&M service code. The S-code S9141 (Diabetic management program, follow-up visit to MD provider) is not separately reimbursed if an appropriate E&M is filed. Use the professional G codes (G0108, G0109) for physician/CDOE/RDN services and the institutional S codes (S9140, S9455, S9460, S9465) for institutional providers as applicable.

G0108 (professional)
G0109 (professional)
S9140 (institutional)
S9141 (not separately reimbursed if E&M filed)
S9455 (institutional)
S9460 (institutional)
S9465 (institutional)

Prior Authorization

Prior authorization not required

Prior authorization review is not required for diabetes self-management education services under this policy.

Billing Rule

Group vs individual session billing

Bill group versus individual diabetes education sessions using the appropriate G code per 30 minutes: G0109 is billed per 30 minutes for group sessions (two or more participants); G0108 is billed per 30 minutes for individual sessions.

G0108 — billed per 30 minutes for individual sessions
G0109 — billed per 30 minutes for group sessions (2 or more)

Background

Background: Rhode Island law RIGL 27-20-30 requires coverage of diabetes self-management education and medical nutrition therapy in addition to diabetes equipment and supplies. Coverage for self-management education and medical nutrition therapy is limited to medically necessary visits occurring at the time of diabetes diagnosis, when a physician documents a significant change in the patient's symptoms or condition necessitating changes in self-management, or for reeducation/refresher training. The statute permits education to be provided by a physician or, upon physician referral, by an appropriately licensed and certified health care provider (including state-certified diabetes educators and registered dietitians/nutritionists), and allows education to be conducted in group settings and to include home visits when medically necessary. This policy addresses applicability to Commercial products and notes that self-funded groups may choose not to follow the state mandate.

OpenPayer

Medical Coverage Policy | Diabetes Self-Management Education Mandate

Coverage Summary

Medical-Necessity Criteria

Coding

Actions for Providers / Billing

Background

Revision History