pre-diabetes, and one screening test per year for individuals previously tested pre-diabetes, or who have never been tested. …
Related Change Request CR : 3677 Related CR Release Date: January 28, 2005 Related CR Transmittal : 457 Effective Date: April 1, 2005 Implementation Date: April 4, 2005
MLN Matters Number: MM3677
MMA - Diabetes Screening Tests
Note: This article was revised on August 17, 2007, to add a reference to a Special Edition MLN Matters article SE0660 http://wwwcmshhsgov/MLNMattersArticles/downloads/se0660pdf that provides updated information about the coverage, eligibility, frequency, and coding guidelines for diabetes screening tests In addition, new preventive services information sources were added to the Additional Information section
Provider Types Affected
All Medicare providers billing Medicare carriers or fiscal intermediaries for diabetes screening tests for Medicare patients
Provider Action Needed
STOP Impact to You This article provides further guidance and clarification of new Medicare coverage rules for diabetes screening tests performed on or after January 1, 2005 CAUTION What You Need to Know The amount of testing covered by Medicare for qualified individuals is changed to one screening test every six months for individuals diagnosed with pre-diabetes and one
screening test every twelve months for individuals not diagnosed with pre-diabetes or who were never tested before GO What You Need to Do Please refer to the Background and Additional Information sections of this article for further details
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations This article may contain references or links to statutes, regulations, or other policy materials The information provided is only intended to be a general summary It is not intended to take the place of either the written law or regulations We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents
Page 1 of 3
Related Change Request : 3677
MLN Matters Number: MM3677
Background
This coverage is mandated by Section 613 of the Medicare Prescription Drug Improvement and Modernization Act of 2003 MMA Initially, coverage was provided for two screening tests per calendar year for individuals diagnosed with pre-diabetes, and one screening test per year for individuals previously tested who were not diagnosed with pre-diabetes, or who
have never been tested This article and related CR 3677 clarify that, for individuals diagnosed with pre-diabetes, the two screening tests per year are further limited to one screening test every six months And, providers should note that these tests for individuals with a pre-diabetes diagnosis must be billed with a V771 diagnosis code and a TS modifier to reflect follow up service Any individual with one 1 of the following risk factors for diabetes is eligible for this benefit: Hypertension Dyslipidemia Obesity with a body mass index greater than or equal to 30 kg/m2, or Previous identification of elevated impaired fasting glucose or glucose intolerance Overweight a body mass index 25, but 30kg/m2 A family history of diabetes Age 65 years or older A history of gestational diabetes mellitus or giving birth to a baby weighing 9 lbs
Or, an individual with any two 2 of the following risk factors is also eligible for this benefit:
Effective for services performed on or after January 1, 2005, Medicare will pay for diabetes screening tests under the Medicare Clinical Laboratory Fee Schedule To indicate that the purpose of the tests is for diabetes screening, a screening
diagnosis code is required in the diagnosis section of the claim The following Health Care Common Procedure Coding System HCPCS Codes for Diabetes Screening are to be billed for diabetes screening: 82947 Glucose, quantitative, blood except reagent strip 82950 Po 
st-glucose dose includes glucose 82951 Glucose Tolerance test GTT, three specimens includes glucose
Providers submitting pre-diabetes and diabetes screening claims should note that claims must contain the appropriate HCPCS codes listed above along with a diagnosis code of V771 No coverage is permitted under the MMA benefit for individuals previously diagnosed as diabetic since these individuals do not require screening Other diabetes screening blood tests for which the Centers for Medicare Medicaid Services CMS has not specifically indicated national coverage continue to be noncovered CMS also provides the following definitions for the purpose of this article:
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations This article may contain references or links to statutes, regulations, or other policy materials The information provided is only intended
to be a general summary It is not intended to take the place of either the written law or regulations We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents
Page 2 of 3
Related Change Request : 3677
MLN Matters Number: MM3677
Diabetes: diabetes mellitus, a condition of abnormal glucose metabolism diagnosed from a fasting blood sugar 126 mg/dL on 2 different occasions; a 2-hour post-glucose challenge 200 mg/dL on 2 different occasions; or a random glucose test 200 mg/dL for an individual with symptoms of uncontrolled diabetes Pre-diabetes: abnormal glucose metabolism diagnosed from a previous fasting glucose level of 100 to125 mg/dL, or a 2-hour post-glucose challenge of 140 to 199 mg/dL The term pre-diabetes includes impaired fasting glucose and impaired glucose tolerance Post-glucose challenge test: an oral glucose tolerance test with a glucose challenge of 75 gms of glucose for non-pregnant adults, or a 2-hour post-glucose challenge test alone
Implementation
The implementation date for this article is April 4, 2005 It applies to services furnished on or after January 1,
2005
Additional Information
Updated manual instructions are included in the official instruction issued to your carrier or fiscal intermediary and can be found at http://wwwcmshhsgov/Transmittals/downloads/R457CPpdf on the CMS website For more information about Medicares diabetes screening benefit, visit the CMS Diabetes Screening web page at http://wwwcmshhsgov/DiabetesScreening/ on the CMS website CMS has also developed a variety of educational products and resources to help healthcare professionals and their staff become familiar with coverage, coding, billing, and reimbursement for all preventive services covered by Medicare: The MLN Preventive Services Educational Products Web Page provides descriptions and ordering information for all provider specific educational products related to preventive services The web page is located at http://wwwcmshhsgov/MLNProducts/35_PreventiveServicesasp on the CMS website If you have any questions, contact your carrier or intermediary at their toll-free number, which may be found at http://wwwcmshhsgov/MLNProducts/downloads/CallCenterTollNumDirectoryzip on the CMS website
Disclaimer
This article was prepared as a service to the public and
is not intended to grant rights or impose obligations This article may contain references or links to statutes, regulations, or other policy materials The information provided is only intended to be a general summary It is not intended to take the place of either the written law or regulations We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents
Page 3 of 3
Source:bcbsil.com
