CCD # GENERAL
MEDICARE + DATE
1 What’s going on with
Medicare for coverage of pre-diabetes?
11-15-12
ANSWER, AUTHOR, REFERENCE
As of November, 2012, Medicare does not cover DSMT or diabetes
MNT for beneficiaries with prediabetes.
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Medicare, however, does covers tests to screen for diabetes if the person is at risk for diabetes or has been diagnosed with pre-diabetes.
A person is eligible for one Medicare-covered diabetes screening every
12 months if he/she:
 has hypertension

 has dyslipidemia (any kind of cholesterol problem) had prior blood test showing glucose intolerance
 is obese (BMI >30), or
 meets at least two of following: o is overweight (BMI 25 to 30); o has family history of diabetes o has history of diabetes during pregnancy (GDM) or have had baby >9 pounds; or o is >65 years old
The Medicare-covered diabetes screening test includes :
 a fasting blood glucose test, and/or
 a post-glucose challenge test
If the person has been diagnosed with pre-diabetes, Medicare will cover two diabetes screening tests every calendar year. Medicare will pay for
100% of its approved amount for the test even before the person has met the Part B deductible. He/she will pay no copay or deductible for these tests if the person sees his/her doctor who takes assignment.
Doctors and other health care providers who take assignment cannot charge more than the Medicare approved amount. If the person is in a
Medicare Advantage plan (private health plan), he/she should check with the plan to see what costs and rules apply. Medicare Advantage
(MA) plans must cover all preventive services the same as Original
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Medicare. This means MA plans are not allowed to charge cost-sharing fees (coinsurances, copays or deductibles) for preventive services that
Original Medicare does not charge fo,r as long as the person sees an in-network provider. If a provider is not in the plan’s network, charges will typically apply.
Changes in reimbursement due to
Obamacare.
11-15-12
Reference for italicized answer: http://www.medicareinteractive.org/page2.php?topic=counselor&page=s cript&slide_id=862 Accessed 11-16-12
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The goal of the Affordable Care Act (ACA) is to increase access to quality, affordable healthcare for uninsured individuals and their families. The new law is being implemented in phases. In September
2010 and include:
 Providing access to insurance for individuals with pre-existing conditions
 Extending coverage for young adults - up to age 26 - on their parents' plans
 Providing free preventative care, such as immunizations and mammograms
 Ending lifetime and most annual limits to care
Below is a list of the ACA’s covered preventive services at no cost related to diabetes and support:
–
Aspirin use for men and women of certain ages
–
Blood pressure screening for all adults
–
Cholesterol screening: adults of certain ages or at high risk
–
Depression screening for adults
–
Type 2 diabetes screening for adults with high BP
–
Diet counseling for adults at higher risk for chronic disease
–
Immunization vaccines
–
Obesity screening and counseling for all adults
–
Tobacco use screening for all adults…plus cessation interventions for
tobacco users
–
GDM screening for women 24--28 wks pregnant and those
at high risk of developing GDM
Very detailed information can be found at: www.healthcare.gov
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CCD #
1
DSME/T + DATE
CCD #
1
MNT + DATE
How to get maximum reimbursement for
MNT for HTN, hyperlipidemia, etc.?
10-18-12
ANSWER, AUTHOR, REFERENCE TOOL?
ANSWER, AUTHOR, REFERENCE
Medicare: We have made the assumption that your question refers to
Medicare. As Medicare does not reimburse for these disorders, the RD is to give the beneficiary an Advance Beneficiary Notice (ABN) prior to furnishing the MNT. The RD must use the most current version of the
ABN form (Form CMS-R-131 (03/11); it can be downloaded from the
CMS website (www.cms.gov), along with specific instructions for its correct use. The form is used to convey to the beneficiary that Medicare is not likely to provide coverage in a specific case. The RD must complete the required fields on the ABN and give the notice to the beneficiary or their representative before providing the noncovered MNT.
The ABN ensures that the beneficiary has all available information to make an informed decision about whether or not to obtain the noncovered services. If the patient opts to have the service, there is a statement on the form that says that he/she will then be responsible for the full estimated payment of $_______________. This is the best way to maximize payment of MNT by Medicare for noncovered services.
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Can we put this
ABN form on website with instructions?
Emailed form + instructions to
Amparo ON 10-
18-12
CCD # METERS, PUMPS +
DATE
ANSWER, AUTHOR, REFERENCE TOOL?
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1 Finding test strips that will be affordable for each participant.
11-15-12
Many medical device companies have patient assistance programs.
Many of these programs are available only through a physician. The
Pharmaceutical Research and Manufacturers of America and its member companies sponsor an interactive website with information about drug assistance programs at www.PPARx.org
Also, because programs for the homeless sometimes provide aid, people can contact a local shelter for more information about how to obtain free medical supplies and even free medications. The number of the nearest shelter may be listed in the phone book under Human
Service Organizations or Social Service Organizations.
Local resources such as the following charitable groups may offer financial help for some of the many expenses related to diabetes:
 Lions Clubs International can help with vision care. www.lionsclubs.org
 Rotary International clubs provide humanitarian and educational assistance. www.rotary.org
 Elks clubs provide charitable activities that benefit youth and veterans. www.elks.org
 Shriners of North America offer free treatment for children at
Shriners hospitals throughout the country. www.shrinershq.org
 Kiwanis International clubs conduct service projects to help children and communities. www.kiwanis.org
In many areas, nonprofit or special-interest groups such as those listed above can sometimes provide financial assistance or help with fundraising. Religious organizations also may offer assistance. In addition, some local governments may have special trusts set up to help people in need. The local library or local city or county government’s health and human services office may provide more information about such groups.
Providers can also refer these patients to their local
American Diabetes Association’s office or call the ADA National Center at 800-DIABETES for advice and more information.
Together Rx Access
The Together Rx Access Card was created by leading pharmaceutical companies to help people gain access to immediate and meaningful savings on prescription products right at their neighborhood pharmacy.
Most cardholders save 25 to 40 percent on brand-name prescription products. More than 300 brand-name prescription products are included in the Program. Savings are also available on a wide range of generics.
Medicines in the Program include those used to treat high cholesterol, diabetes, depression, asthma, and many other common conditions. The
Card is free to get and free to use. To qualify for the free Card ,
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applicants cannot be eligible for Medicare or have public or private prescription drug coverage. Household income levels are also part of the eligibility criteria.
Each cardholder's savings depend on such factors as the particular drug or supply purchased, amount purchased, and the pharmacy where purchased. Participating companies independently set the level of savings offered and the products included in the program. Those decisions are subject to change.
Contact Information
Together Rx Access LLC
P.O. Box 9426, Wilmington, DE 19809-9944
1-(888) 743-7214
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CCD #
1
CGM + DATE
CCD # MEDICATION
MANAGE-
MENT + DATE
1
CCD # POC TESTING +
DATE
1
CCD # EVALUATION &
MANAGEMENT
SERVICES
+ DATE
1
CCD # OTHER + DATE
1 What ICD9 codes will cover rationale for starting patient on diabetes medication when A1c is 5.8 to
6.4 (pre-diabetes)?
ANSWER, AUTHOR REFERENCE
ANSWER, AUTHOR, REFERENCE
ANSWER, AUTHOR, REFERENCE
ANSWER, AUTHOR, REFERENCE
ANSWER, AUTHOR, REFERENCE
Selecting the right ICD-9 diagnosis code for pre-diabetes depends on what you know about the patient's BG status, and what has been clearly docum ented in the patient’s chart. In 2012, these codes apply to prediabetes conditions:
 790.21 Impaired fasting glucose o Elevated fasting glucose
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2 How can one obtain reimbursement for a virtual visit (i.e., telephone, email,
Internet)?
 790.29 Other abnormal glucose o Abnormal glucose NOS (not otherwise specified) o Abnormal non-fasting glucose o Hyperglycemia NOS o Pre-diabetes NOS
 277.7 Dysmetabolic syndrome X o Use additional code for associated manifestation, such as: cardiovascular disease (414.00-414.07), obesity (278.00-
278.01)
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More and more private and commercial healthcare plans are now paying for telephone, email and online healthcare interventions (often times referred to as “e-visits”). Note that “online” may be characterized as an interv ention between the patient and provider on either’s website, and may include: both audio and visual communication on a specific website; only audio; or only written communication on the website.
Virtual visits are seen as a tool that will save money, provide convenient care and help solve the problem of patients not having access to their providers. These visits are on the verge of entering mainstream medicine.
Below are key ways to determine if a patient’s healthcare plan covers these types of visits, whether for medical evaluation and management,
DSMT, MNT, etc.:
 Patient calls his/her specific plan and inquires
 Provider call the specific plan and inquires
 Patient and/or provider accesses the plan’s website
Medicare reimbursement for telephone and email interventions is not provided as of November, 2012. However, Medicare does reimbursement for initial and followup DSMT and MNT “telehealth”, furnished either individually or in group. Providers and diabetes educat ors must comply with all of Medicare’s coverage guidelines, and ensure that the real-time audio-visual platform/software that is used meets HIPAA guidelines for protected health information (PHI) ….i.e., secured communication portal is used due to the fact that the PHI is being transmitted in cyperspace. The “visual” requirement means that the patients and the providers “see” each other through a video linkup with the aid of a webcam.
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3 With pay-forperformance, how will this impact the patient-centered medical home?
11-15-12
Pay-for-performance (P4P) can be defined as a payment or financial incentive (e.g., a bonus) associated with achieving defined and measurable goals related to care processes and outcomes, patient experience, resource use, and other factors.
1 One major study determined that among the types of care best suited for P4P are services for which metrics already exist including management of some chronic conditions (e.g., diabetes, asthma, heart failure) and certain surgeries.
1
Now with regard to patient-centered medical homes (PCMH), first a brief overview. Most PCMHs rely on the joint principles of the PCMH developed by the primary care physician specialty societies, which lay out the general attributes of this type of care modality. They emphasize
4 key primary care elements: accessibility, continuity, coordination and comprehensiveness. Research shows positively affect health outcomes, patient and provider satisfaction and costs.
2
Although P4P programs may drive improvements in care that can be measured, such “measured” care may be inconsistent with patient preferences, and may be inconsistent with the 4 key primary care elements of the PCMH. P4Ps with rigid measures and standards could create incentives for physicians to avoid high-risk patients and fire noncompliant ones. In addition, the administrative work associated with data collection and reporting may take time that otherwise could be devoted to direct patient care, thus distracting physicians from actually improving care for patients.
1 P4P programs that are overly burdensome with copious documentation requirements may not improve patient outcomes for these reasons. They may also increase the risk of posing a barrier to practices seeking to participate as medical homes.
1
References:
1. Five Payment Models: The Pros, the Cons, the Potential,
Silversmith, Janet, on behalf of the Minnesota Medical Association
Work Group to Advance Health Care Reform
www.minnesotamedicine.com/tabid/3679/Default.aspx
2. Qualifying a Physician Practice as a Medical Home, O'Malley, Ann
S., Peikes, Deborah and Ginsburg, Paul B.
www.hschange.org/CONTENT/1030/1030.pdf
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CCD #
REIMBURSEMENT TOOLS
NOW
ON WEBSITE
1 Encounter Form (Reinhard developed one for JJDI manual on a PPT slide)
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2 Medicare MNT – DSMT Hours Tracking Form (Mary Ann)
3 Reimbursement Tracking Form (Mary Ann)
4 Quick Guide to MNT – DSMT (Mary Ann)
5 Universal DSMT – MNT Order Form
CCD # REIMBURSEMENT TOOLS
SUGGESTED
FOR WEBSITE (PER ABOVE ANSWERS) TEAM COMMENTS
1 ABN form CMS-R-131 (03/11) and accompanying instructions
THE INFORMATION REGARDING REIMBURSEMENT IS PROVIDED FOR INFORMATIONAL PURPOSES ONLY AND REPRESENTS NO STATEMENT,
PROMISE, OR GUARANTEE BY THE JOHNSON & JOHNSON DIABETES INSTITUTE, LLC CONCERNING LEVELS OF REIMBURSEMENT, PAYMENT, OR
CHARGE. SIMILARLY, ALL CPT AND HCPCS CODES ARE SUPPLIED FOR INFORMATIONAL PURPOSES ONLY AND REPRESENT NO STATEMENT,
PROMISE, OR GUARANTEE BY THE JOHNSON & JOHNSON DIABETES INSTITUTE, LLC THAT THESE CODES WILL BE APPROPRIATE OR THAT
REIMBURSEMENT WILL BE MADE. IT IS NOT INTENDED TO INCREASE OR MAXIMIZE REIMBURSEMENT BY ANY PAYOR. WE STRONGLY
RECOMMEND THAT YOU CONSULT YOUR PAYOR ORGANIZATION WITH REGARD TO ITS REIMBURSEMENT POLICIES.
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