Guidelines for Coverage of Hospital Outpatient Diabetes Education Programs

1. Program Requirements:
   1. The program must be hospital-based (an outpatient hospital service) or the program must be affiliated with a Medicare-approved rural health clinic.
   2. The program must have a physician medical director who, by training or experience, is knowledgeable about diabetes mellitus.
   3. The non-physician staff members who are involved with patient education must have training and/or experience in diabetic education. Such personnel would include diabetic nurse educators or dietitians.
   4. If a hospital outpatient diabetic education program is not Medicare approved, but the program has received a certificate of recognition by the American Diabetes Association, a copy of the certificate must be mailed to the address below:
      
      Blue Cross and Blue Shield of Alabama
      Attn: Network Services
      450 Riverchase Parkway East
      Birmingham, Alabama 35244
   5. The education program must be designed in such a way that it is directed toward the specific needs of the individual patient.
2. For services rendered to an individual patient, the following requirements must be satisfied before reimbursement can be made to an approved diabetic education program:
   1. The patient must be referred by his/her treating or primary care physician.
   2. The patient’s condition must be such that the initiation of insulin therapy is required and that the diabetic education required is beyond that which is routinely provided by a physician’s office, and must also meet one of the following requirements:
      1. Be a newly diagnosed diabetic
      2. Have unstable diabetes mellitis
      3. Be a chronic diabetic with a new management problem which is related to the diabetes
   3. The patient must not have previously completed a formal diabetic education program. In general, payment will be allowed for diabetic education only once in a lifetime unless there is some compelling reason for the patient to repeat a diabetic education program.
3. Billing Information:
   1. Revenue code 942 should be used to bill for each diabetic education “session.” A “session” is defined as all the diabetic education rendered on the same date to a patient. The length of the session might vary, however, only one revenue code (942) should be submitted for education services rendered on a given date. Codes 99078,G0108 and/or G0109 must be placed in form locator 43. The units keyed in form locator 46 will count towards the 5 units maximum.
   2. A maximum of five diabetic education sessions can be allowed per lifetime, unless there is some compelling reason for the patient to receive more extensive diabetic education. The allowance is $30 per session.
   3. If a patient is to attend a series of sessions sequentially in order to complete a diabetic education program, then all sessions should be billed on a single UB-04 claim form. For instance, if a patient completes one sessions per day over a five day period, then revenue code 942 should be placed in form locator 42 with the number of sessions (units) "5" placed in form locator 46 of the UB-04.
4. Non-Covered Items or Services:
   1. Food
   2. Diabetic education programs for a stable, non-newly diagnosed diabetic (i.e., patient has had diabetes greater than six months) or one not requiring injectable insulin therapy
   3. Exercise regimen for overall health and fitness
5. Currently Approved Facilities:

   Baptist Hospital

   Brookwood Medical Center

   Children’s Hospital Inc

   Crockett Hospital LLC

   DCH Regional Medical Center

   Decatur General Hospital

   East Alabama Medical Center

   Gadsden Regional Medical Center

   Huntsville Hospital

   Jackson Hospital

   Jeff Anderson Regional Medical Center

   Mobile Infirmary Medical Center

   Princeton Baptist Medical Center

   Providence Hospital

   Sacred Heart Hospital

   Southeast Alabama Medical Center

   Springhill Memorial Hospital

   St Francis Hospital Inc

   St Vincent’s Birmingham

   St Vincent’s East

   The Kirklin Clinic Ambulatory Surgical Center

   Thomas Hospital

   Trinity Medical Center

   Veterans Administration Medical Center Birmingham

   West Florida Hospital