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Contract Type HHH MAC

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Page 1 of 5 Skip to Main Content Main Menu Centers for Medicare & Medicaid Services Print Message: If you are experiencing issues printing this page, then please click Return to Previous Page and select the 'Need a PDF?' button. You can now print the page from the new popup window. Back to Local Coverage Determinations (LCDs) for Palmetto GBA (11004, HHH MAC) Local Coverage Determination (LCD): Home Health Plans of Care: Monitoring Glucose Control in the Medicare Home Health Population with Type II Diabetes Mellitus (L35413) Contractor Information Contractor Name Palmetto GBA Contract Number Contract Type HHH MAC LCD Information Document Information LCD ID L35413 LCD Title Home Health Plans of Care: Monitoring Glucose Control in the Medicare Home Health Population with Type II Diabetes Mellitus AMA CPT / ADA CDT / AHA NUBC Copyright Statement CPT only copyright American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright American Dental Association. All rights reserved. CDT and CDT are trademarks of the American Dental Association. UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL, 2014, is copyrighted by American Hospital Association ( AHA ), Chicago, Illinois. No portion of OFFICIAL UB-04 MANUAL may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA. Health Forum reserves the right to change the copyright notice from time to time upon written notice to Company. Jurisdiction Alabama Arkansas Florida Georgia Illinois Indiana Kentucky Louisiana Mississippi North Carolina New Mexico Ohio Oklahoma South Carolina Tennessee Texas Original Effective Date For services performed on or after 12/30/2014 Revision Effective Date Revision Ending Date Retirement Date Notice Period Start Date 11/14/2014 Notice Period End Date 12/29/2014 CMS National Coverage Policy Title XVIII of the Social Security Act, 1862 (a)(1)(a) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Title XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim. Page 2 of 5 CMS Internet-Only Manual, Pub Medicare Benefit Policy Manual, Chapter 7, 20.2 CMS Internet-Only Manual, Pub Medicare Benefit Policy Manual, Chapter 7, CMS Internet-Only Manual, Pub Medicare Benefit Policy Manual, Chapter 7, Coverage Guidance Coverage Indications, Limitations, and/or Medical Necessity The goal of this Local Coverage Determination (LCD) is to ensure that evidence-based medicine addressing the risks of acute and chronic complications of diabetes mellitus are integrated into the delivery of home health services for Medicare beneficiaries with type II diabetes mellitus. Initial treatment of individuals diagnosed with diabetes mellitus must take into account many factors, including the level of hyperglycemia and comorbidities i. Physicians often recommend diet, exercise, and medications alone or in combination to help reduce long-term risks of hyperglycemia. When a daily medication is required the first-line agent is generally an oral medication like Metformin, unless there is a contraindication to its use. This policy establishes the expectation that for those Medicare beneficiaries requiring medications to achieve long-term control of glucose levels, Metformin shall be considered first-line therapy unless there is a specific contraindication to its use. Likewise Medicare beneficiaries who despite being maintained on daily insulin regimens are poorly controlled should be considered for treatment with Metformin. Skilled nurse visits are permitted for the administration of daily insulin injections for the population of Medicare beneficiaries that are either physically or mentally unable to self-inject insulin and there is no other person who is able and willing to inject the beneficiary. Reasonable and necessary plans of care must contain sufficient information concerning the identified functional limitations to explain why an individual is physically or mentally unable to self-inject insulin. In the absence of another skilled service, failure to include the specific structural or functional impairments, together with the related activity limitations, to support the determination that the individual beneficiary is either physically or mentally unable to self-inject insulin will result in a claim denial. Evidence-based medicine supports ascertaining glucose control and the risk of secondary conditions, known to occur in individuals with diabetes mellitus, by monitoring glucose and hemoglobin A1c (HbA1c) levels in individuals with diabetes mellitus ii. This information, and its communication between the physician and home health agency caring for a given beneficiary, helps ensure that a home health plan of care is not only patient-centered, but also addresses prognosis - as required by the Medicare Benefit Policy Manual iii. Reasonable and necessary home health plans of care for Medicare beneficiaries with Type II diabetes must therefore include the monitoring and reporting of not only intermittent capillary blood/serum glucose levels but also quarterly (and no less often than 120 days) HbA1c levels. Coding Information Bill Type Codes: Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims. 032x Home Health - Inpatient (plan of treatment under Part B only) 033x Home Health - Outpatient (plan of treatment under Part A, including DME under Part A) Revenue Codes: Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes Skilled Nursing - General Classification CPT/HCPCS Codes Group 1 Paragraph: Group 1 Codes: G0154 DIRECT SKILLED NURSING SERVICES OF A LICENSED NURSE (LPN OR RN) IN THE HOME HEALTH OR HOSPICE SETTING, EACH 15 MINUTES Page 3 of 5 ICD-9 Codes that Support Medical Necessity Group 1 Paragraph: Group 1 Codes: DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE II OR UNSPECIFIED TYPE, DIABETES WITH KETOACIDOSIS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS DIABETES WITH KETOACIDOSIS, TYPE II OR UNSPECIFIED TYPE, DIABETES WITH HYPEROSMOLARITY, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS DIABETES WITH HYPEROSMOLARITY, TYPE II OR UNSPECIFIED TYPE, DIABETES WITH OTHER COMA, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS DIABETES WITH OTHER COMA, TYPE II OR UNSPECIFIED TYPE, V58.67* DIABETES WITH RENAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS DIABETES WITH RENAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II OR UNSPECIFIED TYPE, DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, DIABETES WITH UNSPECIFIED COMPLICATION, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS DIABETES WITH UNSPECIFIED COMPLICATION, TYPE II OR UNSPECIFIED TYPE, LONG-TERM (CURRENT) USE OF INSULIN Group 1 Medical Necessity ICD-9 Codes Asterisk Explanation: * V58.67 is the code used for insulin requiring diabetes mellitus. Documentation must show that patient is on insulin as indicated by the v code and must be billed with one of the type 2 diabetes codes. Page 4 of 5 ICD-9 Codes that DO NOT Support Medical Necessity Paragraph: Codes: XX000 Not Applicable General Information Associated Information Documentation Requirements 1. Documentation should show that patient is either physically or mentally unable to self-inject insulin and there is no other person who is able and willing to inject the patient. 2. The results of the most recent HbA1c. 3. Documentation must be legible, relevant and sufficient to justify the services billed. This documentation must be made available to the A/B MAC upon request. Sources of Information and Basis for Decision i. Nathan DM, Buse JB, Davidson MB, et al. Medical management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy: a consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes Diabetes Care; 32:193. ii. Koller EA, Chin JS, Conway PH. Diabetes Prevention and the Role of Risk Factor Reduction in the Medicare Population. Am J Prev Med 2013;44(4S4):S iii. CMS Internet-Only Manual, Pub Medicare Benefit Policy Manual, Chapter 7, Revision History Information Back to Top Associated Documents Attachments Related Local Coverage Documents Article(s) A Response to Comments for Home Health Plans of Care: Monitoring Glucose Control in the Medicare Home Health Population with Type II Diabetes Mellitus LCDs L35413 and L35132 Related National Coverage Documents Public Version(s) Updated on 11/07/2014 with effective dates 12/30/ Keywords Home Health Diabetes Insulin Glucose Monitoring Page 5 of 5 Read the LCD Disclaimer 11
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