Medicare Diabetes Screening Billing Guidelines

Medicare Diabetes Screening Billing

Medicare Part B covers patients with certain diabetes risk factors or diagnosed with pre-diabetes. But note that patients previously diagnosed with diabetes aren’t eligible for diabetes screening benefits. Medicare covers 1 screening every 6 months for patients diagnosed with pre-diabetes and 1 screening every 12 months if previously tested but not diagnosed with pre-diabetes or if never tested. In such screening, the patient doesn’t pay co-payment, coinsurance, or deductibles. While billing for Medicare append modifier –TS (Follow-up service) when patients meet the pre-diabetes definition. Medicare pays to order providers’ and Durable Medical Equipment (DME) suppliers’ DME claims when they’re actively enrolled in Medicare on the service date or, in the case of the provider, have a valid opt-out affidavit on file. If you don’t participate in Medicare, tell your patients before you order DME.

Diabetes Screening CPT Codes

Applicable diagnosis codes and procedure codes are as follows:

  • 82947: Glucose; quantitative, blood (except reagent strip)
  • 82950: Glucose; post glucose dose (includes glucose)
  • 82951: Glucose; tolerance test (GTT), 3 specimens (includes glucose)
  • ICD-10 code: Z13.1. Note that additional ICD-10 codes may apply. Find individual Change Requests (CRs) and specific ICD-10-CM service codes that Medicare cover on the CMS ICD-10 webpage. Or you can refer to your MAC’s website for more information.

Defining Primary Care Setting

Defining the primary care setting is really important to get reimbursed for Medicare diabetes screening services. CMS defines a primary care setting as a place where clinicians deliver integrated, accessible healthcare services, are responsible for addressing most patient healthcare needs, developing a sustained patient partnership, and practicing in the context of family and community. Under this direction, CMS doesn’t consider emergency departments, inpatient hospital settings, ambulatory surgical centers, independent diagnostic testing facilities, skilled nursing facilities, inpatient rehabilitation facilities, and hospices as primary care settings.

Medicare Diabetes Prevention Program (MDPP)

The Medicare Diabetes Prevention Program expanded model is a structured intervention with the goal of preventing type 2 diabetes in individuals with an indication of prediabetes. The clinical intervention consists of a minimum of 16 intensive ‘core’ sessions of a Centers for Disease Control and Prevention (CDC) approved curriculum furnished over six months in a group-based, classroom-style setting that provides practical training in long-term dietary change, increased physical activity, and behavior change strategies for weight control.

After completing the core sessions, less intensive follow-up meetings furnished monthly help ensure that the participants maintain healthy behaviors. The primary goal of the expanded model is at least 5 percent weight loss by participants. The study found that lifestyle changes resulting in modest weight loss sharply reduced the development of type 2 diabetes in people at high risk for the disease.

For providers or healthcare organizations, it takes at least 12 months to obtain CDC preliminary recognition and up to 24 additional months to achieve full recognition. Preliminary recognition requires the submission of 12 months of data from a National DPP cohort. Full CDC recognition requires that organizations deliver the year-long diabetes prevention lifestyle change program with fidelity to all CDC Diabetes Prevention Recognition Program (DPRP) Standards.

This recognition status could be achieved within 36 months if all requirements are met. All requirements to achieve CDC Full Recognition status are listed in the CDC DPRP standards and include using a CDC-approved curriculum, meeting attendance-based requirements, and meeting standards related to the rate at which participants achieve the final 5 percent or more weight loss goal.

Medical Billers and Coders (MBC) is a leading medical billing company providing complete medical billing and coding services. To explain Medicare diabetes screening billing guidelines we referred to the CMS webpage for Medicare Preventive Services and Medicare Diabetes Prevention Program (MDPP) for a detailed understanding. To receive accurate reimbursement from Medicare, Medicaid, and other private insurance carriers, email us at: info@medicalbillersandcoders.com or call us: 888-357-3226.