Pre-Diabetes Screening involves the testing of asymptomatic, high-risk individuals to assess whether they meet the criteria for either prediabetes or type 2 diabetes. Screening for prediabetes and diabetes is more frequently done in health care settings than in community settings. The process used to target and test patients may include a team approach, employing various health care professionals such as medical assistants, nurses, physicians, diabetes educators, or others.
Health care providers in a variety of practice settings can consider the use of standard ordering protocols for glucose testing, which may be approved by physicians upfront but carried out by other team members when at-risk patients are identified. In addition, provider teams can look for opportunities to screen for pre-diabetes while managing a patient’s other conditions. For example, when screening for hyperlipidemia, fasting glucose may easily be added to a standard fasting lipid test panel.
Reimbursement for Pre-Diabetes Screening
Medicare recommends and provides coverage for diabetes screening tests through Part B Preventive Services for beneficiaries at risk for diabetes or those diagnosed with pre-diabetes. When filing claims to Medicare for diabetes screening tests, the following Healthcare Common Procedure Coding System (HCPCS) codes, Current Procedural Terminology (CPT) codes and diagnosis codes must be used to ensure proper reimbursement.
|Glucose; quantitative, blood (except reagent strip)
|Glucose; post glucose dose (includes glucose)
|Glucose Tolerance Test (GTT); three specimens (includes glucose)
|DOES NOT MEET
|To indicate that the purpose of the test(s) is diabetes screening for a beneficiary who does not meet the definition of pre-diabetes. The screening diagnosis code V77.1 is required in the header diagnosis section of the claim.
|To indicate that the purpose of the test(s) is diabetes screening for a beneficiary who meets the *definition of pre-diabetes. The screening diagnosis code V77.1 is required in the header diagnosis section of the claim and the modifier “TS” (follow-up service) is to be reported on the line item.
The Centers for Medicare and Medicaid Services (CMS) monitors the use of its preventive and screening benefits. When submitting a claim for a diabetes screening test, it is important to use diagnosis code V77.1 and the “TS” modifier on the claim as indicated in Table 2 above, along with the correct HCPCS/CPT code (Table 1), so that the provider/supplier can be reimbursed correctly for a screening service and not for another type of diabetes testing service.
Medicare beneficiaries who have any of the following risk factors for diabetes are eligible for this screening benefit Hypertension; Dyslipidemia; Obesity (a body mass index equal to or greater than 30 kg/m2); Previous identification of elevated impaired fasting glucose or glucose tolerance. Medicare beneficiaries who have a risk factor consisting of at least two of the following characteristics are eligible for this screening benefit:
- Overweight (a body mass index greater than 25, but less than 30 kg/m2)
- A family history of diabetes
- Age 65 years or older
- A history of gestational diabetes mellitus or of delivering a baby weighing greater than 9 pounds
Intensive Behavioral Therapy for obesity
Effective in 2011, Medicare covers intensive behavioral counseling and behavioral therapy to promote sustained weight loss for Medicare beneficiaries. Many Medicare patients with prediabetes are eligible for this benefit. To be compensated by Medicare, the professional who is offering the counseling must be a primary health care provider delivering the counseling interventions in a health care setting.
- The HCPCS Code for IBT is G0447 for Face-to-face behavioral counseling for obesity, 15 minutes.
- Payment to the provider is currently being made on a fee-for-service basis, with Medicare covering up to 22 IBT encounters in a 12-month period:
- One face-to-face visit every week for the first month
- One face-to-face visit every other week for months 2–6
- One face-to-face visit every month for months 7–12, if the beneficiary meets the 3 kg (6.6 pounds) weight loss requirement during the first 6 months
The beneficiary pays nothing (no coinsurance or co-payment and no Medicare Part B deductible) for IBT for obesity if the provider accepts the assignment.
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