The Washington Health System Diabetes Education and Management Program
Outpatient Services Request
Fax completed request to 724 250 6263
Patient Name_____________________________________________Date of Birth________________________
Telephone: Home (
Diagnosis ()
)
______Newly Diagnosed
______Gestational Diabetes
________________Other (
)
______Insurance
______ _____
______Type 1 Diabetes, out of control
______Type 2 Diabetes, out of control
______Pre surgery patient with A1c over 9
Other:________________________
Requested Service(s) ()
_______Basic diabetes education: Life Skills Series –includes assessment, self blood glucose monitoring, labs (HbA1C, lipid profile,
microalbumin), MNT, and year end review session.
__________Needs
99203, 97802, G0108, G0109
Assessment only—referring physician/CRNP/PA to be contacted for intervention approval 99203, G0108
_______Gestational Diabetes Education/Nutrition Counseling: 2000 cal diet and SBGM if indicated G0108, G0109
_______Basic Meal Planning/Nutrition Counseling (up to 2 hours of group or individual instruction) G0108, G0109
_______ Medical Nutrition Therapy (individual nutrition prescription/meal planning for renal, obesity, CVD, eating disorders, and gastrointestinal Dx).
Nutrition prescription determined by RD; non-DM/renal Dx may not be reimbursed by insurance--patient is responsible for determining coverage. 97802 (initial),
97803 (subsequent)
_______Self blood glucose monitoring (includes issuing a meter as needed and instruction) G0108, G0109
Insulin Therapy (includes start and dose refinement) 99203, G0108
CDE will calculate and adjust dose (unless directed not to do so) as follows:
1. Starting dose- 0.3 – 0.5 units/kg
2. Titrate by 5-20% to target glycemic goals: (80-120 mg/dl Premeal; <140 mg/dl 2 hour post meal; > 100 mg/dl bedtime)
_______Start Lantus or Levemir while continuing oral agents ___________________________________________
_______Lantus or Levemir daily with meal time analog (Novolog, Humalog or Apidra)________________________
Use set meal time doses or teach carb counting based on CDE assessment and patient’s willingness/ability
Use sliding scale dose for correction of high sugars (1700/TDD).
_______Novolog Mix 70/30 or Humalog Mix 75/25 bid
_______Specific insulin order_________________________________________________________________________
_______ Insulin Start Only (CDE will instruct on insulin properties, administration of insulin, hypoglycemia protocol and the patient will be
advised that the prescribing healthcare provider will do dose refinement)
_________
Hormone Injection Therapy instruction (Byetta, Bydureon, Tanzeum, Symlin, Victoza)
_______Insulin Pump Evaluation/Start (includes explanation of pump concepts, completion of CMN, pump start training, dose
refinement and carb counting instruction)
________Continuous Glucose Sensor (includes sensor concepts, completion of CMN, sensor training, dose refinement if appropriate)
________Continuous Glucose Monitoring (3-4 day diagnostic study with report sent to ordering physician) 99203
___________Annual
Review Session—only for patients who have attended the 10 hours of basic education in a previous year.
__________Pre-op
as indicated above.)
diabetes management (includes assessment, self blood glucose monitoring, education as appropriate, and insulin therapy
__________ Other___________________________________________________________________________________
Physician /CRNP/PA Signature __________________________________
Date____________________________
Print MD Name_______________________________________________
Diabetes Education & Management Program
95 Leonard Ave, Building #2, Suite 501
Washington, PA 15301
Telephone: (724) 250-6262
Fax:
(724) 250-6263
11/11/2014