(Medicare Benefit Policy Manual)

Services ordinarily considered routine might also be covered if they are performed as a necessary and integral part of otherwise covered services, such as diagnosis and treatment of diabetic ulcers, wounds, and infections.   G.  Application of Foot Care Exclusions to Physicians Services   The exclusion of foot care is determined by the nature of the service. Thus, payment for an excluded service should be denied whether performed by a podiatrist, osteopath, or a doctor of medicine, and without regard to the difficulty or complexity of the procedure.   When an itemized bill shows both covered services and noncovered services not integrally related to the covered service, the portion of charges attributable to the noncovered services should be denied.  (For example, if an itemized bill shows surgery for an ingrown toenail and also removal of calluses not necessary for the performance of toe surgery, any additional charge attributable to removal of the calluses should be denied.)   In reviewing claims involving foot care, the A/B MAC (B) should be alert to the following exceptional situations:   1. Payment may be made for incidental noncovered services performed as a necessary and integral part of, and secondary to, a covered procedure.  For example, if trimming of toenails is required for application of a cast to a fractured foot, the A/B MAC (B) need not allocate and deny a portion of the charge for the trimming of the nails.  However, a separately itemized charge for such excluded service should be disallowed. When the primary procedure is covered the administration of anest hesia necessary for the performance of such procedure is also covered.   2. Payment may be made for initial diagnostic services performed in connection with a specific symptom or complaint if it seems likely that its treatment would be covered even though the resulting diagnosis may be one requiring only noncovered care.   The name of the M.D. or D.O. who diagnosed the complicating condition must be submitted with the claim.  In those cases, where active care is required, the approximate date the beneficiary was last seen by such physician must also be indicated.  NOTE:  Section 939 of P.L. 96-499 removed warts from the routine foot care exclusion effective July 1, 1981.  Relatively few claims for routine -type care are anticipated considering the severity of conditions contemplated as the basis for this exception.  Claims for this type of foot care should not be paid in the absence of convincing evidence that nonprofessiona l performance of the service would have been hazardous for the beneficiary because of an underlying systemic disease. The mere statement of a diagnosis such as those mentioned in D above does not of itself indicate the severity of the condition.  Where development is indicated to verify diagnosis and/or severity the A/B MAC (B) should follow existing claims processing practices, which may include review of A/B MAC (B)s history and medical consultation as well as physician contacts.   The rules in 290.F concerning presumption of coverage also apply.  Codes and policies for routine foot care and supportive devices for the feet are not exclusively for the use of podiatrists. These codes must be used to report foot care services regardless of the specialty of the physician who furnishes the services.  A/B MACs (B) must instruct physicians to use the most appropriate code available when billing for routine foot care.  300 - Diabetes Self -Management Training Services (Rev. 72, Issued:  05-25- 07; Effective:  07 -01-07; Implementation:  07-02-07)  Section 4105 of the Balanced Budget Act of 1997 permits Medicare coverage of diabetes self-management training (DSMT) services when these services are furnished by a certified provider who meets certain quality standards.  This program is intended to educate beneficiaries in the successful self -management of diabetes.  The program includes instructions in self-monitoring of blood glucose; education about diet and exercise; an insulin treatment plan developed specifically for the patient who is insulin-depen dent; and motivation for patients to use the skills for self- management.   Diabetes self -management training services may be covered by Medicare only if the treating physician or treating qualified non- physician practitioner who is managing the beneficiarys diabetic condition certifies that such services are needed.  The referri ng physician or qualified non- physician practitioner must maintain the plan of care in the beneficiarys medical record and documentation substantiating the need for training on an individual basis when group training is typically covered, if so ordered.  The order must also include a statement signed by the physician that the service is needed as well as the following:    The number of initial or follow -up hours ordered (the physician can order less than 10 hours of training);    The topics to be covered in training (initial training hours can be used for the full initial training program or specific areas such as nutrition or insulin training); and   A determination that the beneficiary should receive individual or group training.  The provider of the service must maintain documentation in a file that includes the original order from the physician and any special conditions noted by the physician.  When the training under the order is changed, the training order/referral must be signed by the physician or qualified non- physician practitioner treating the beneficiary and maintained in the beneficiarys file in the DSMTs program records.   NOTE:   All entities billing for DSMT under the fee-for-service payment system or other payment systems must meet all national coverage requirements.   300.1 - Beneficiaries Eligible for Coverage and Definition of Diabetes  (Rev. 13, 05- 13-04)  Medicare Part B covers 10 hours of initial training for a beneficiary who has been diagnosed with diabetes.   Diabetes is diabetes mellitus, a condition of abnormal glucose metabolism diagnosed using the following criteria;    a fasting blood sugar greater than or equal to 126 mg/dL on two different occasions;    a 2 hour post -glucose challenge greater than or equal to 200 mg/dL on 2 different occasions; or   o a random glucose test over 200 mg/dL for a person with symptoms of uncontrolled diabetes.   Documentation that the beneficiary is diabetic is maintained in the beneficiarys medical record.   Beneficiaries are eligible to receive follow -up training each calendar year following the year in which they have been certified as requiring initial training or they may receive follow -up training when ordered even if Medicare does not have documentation that initial training has been received.  In that instance, contractors shall not deny the follow -up service even though there is no initial training recorded.   300.2 - Certified Providers  (Rev. 109; Issued:  08- 07-09; Effective Date:  03 -30-09; Implementation Date:  09-08-09)  A designated certified provider bills for DSMT provided by an accredited DSMT program.  Certified providers must submit a copy of their accreditation certificate to the contractor.  The statute states that a certified provider is a physician or other ind ividual or entity designated by the Secretary that, in addition to providing outpatient self -management training services, provides other items and services for which payment may be made under title XVIII, and meets certain quality standards.  The CMS is designating all providers and suppliers that bill Medicare for other individual services such as hospital outpatient departments, renal dialysis facilities, physicians and durable medical equipment suppliers as certified.  All suppliers/providers who may bi ll for other Medicare services or items and who represent a DSMT program that is accredited as meeting quality standards can bill and receive payment for the entire DSMT program.  Registered dietitians are eligible to bill on behalf of an entire DSMT progr am on or after January 1, 2002, as long as the provider has obtained a Medicare provider number.  A dietitian may not be the sole provider of the DSMT service.  There is an exception for rural areas.  In a rural area, an individual who is qualified as a re gistered dietitian and as a certified diabetic educator who is currently certified by an organization approved by CMS may furnish training and is deemed to meet the multidisciplinary team requirement.   The CMS will not reimburse services on a fee- for-service basis rendered to a beneficiary under Part A.   NOTE:   While separate payment is not made for this service to Rural Health Clinics (RHCs), the service is covered but is considered included in the all -inclusive encounter rate.  Effective January 1, 2006, payment for DSMT provided in a Federally Qualified Heal th Clinic (FQHC) that meets all of the requirements identified in Pub. 100 -04, chapter 18, section 120 may be made in addition to one other visit the beneficiary had during the same day.   All DSMT programs must be accredited as meeting quality standards by a CMS approved national accreditation organization.  Currently, CMS recognizes the American Diabetes Association, American Association of Diabetes Educators and the Indian Health Service as approved national accreditation organizations. Programs without accreditation by a CMS -approved national accreditation organization are not covered.  Certified provide rs may be asked to submit updated accreditation documents at any time or to submit outcome data to an organization designated by CMS.  Enrollment of DMEPOS Suppliers   The DMEPOS suppliers are reimbursed for diabetes training through A/B MACs (B).  In order to file claims for DSMT, a DMEPOS supplier must be enrolled in the Medicare program with the National Supplier Clearinghouse (NSC).  The supplier must also meet the q uality standards of a CMS -approved national accreditation organization as stated above.  DMEPOS suppliers must obtain a provider number from the A/B MAC (B) in order to bill for DSMT.   The A/B MAC (B) requires a completed Form CMS -855, along with an accreditation certificate as part of the provider application process.  After it has been determined that the quality standards are met, a billing number is assigned to the supplier.  Once a supplier has received a National Provider Identification (NPI) number, the supplier can begin receiving reimbursement for this service.   A/B MACs (B) should contact the National Supplier Clearinghouse (NSC) according to the instruction in Pub 100- 08, the Medicare Program Integrity Manual, Chapter 10, Healthcare Provider/Supplier Enrollment, to verify an applicant is currently enrolled and eligible to receive direct payment from the Medicare program.   The applicant is assigned specialty 87.  Any DMEPOS supplier that has its billing privileges deactivated or revoked by the NSC will also have the billing number deactivated by the A/B MAC (B).  300.3 - Frequency of Training  (Rev. 72, Issued:  05- 25-07; Effective:  07 -01-07; Implementation:  07- 02-07)  A - Initial Training   The initial year for DSMT is the 12 month period following the initial date.   Medicare will cover initial training that meets the following conditions:    Is furnished to a beneficiary who has not previously received initial or follow -up training under HCPCS codes G0108 or G0109;    Is furnished within a continuous 12- month period;    Does not exceed a total of 10 hours* (the 10 hours of training can be done in any combination of 1/2 hour increments);    With the exception of 1 hour of individual training,  training is usually furnished in a group setting, which can contain other patients besides Medicare beneficiaries, and;    One hour of individual training may be used for any part of the training including insulin training.   * When a claim contains a DSMT HCPCS code and the associated units cause the total time for the DSMT initial year to exceed '10' hours, a CWF error will set.  B - Follow -Up Training   Medicare covers follow -up training under the following conditions:    No more than 2 hours individual or group training per beneficiary per year;    Group training consists of 2 to 20 individuals who need not all be Medicare beneficiaries;    Follow -up training for subsequent years is based on a 12 month calendar after completion of the full 10 hours of initial training;    Follow -up training is furnished in increments of no less than one -half hour*; and    The physician (or qualified non- physician practitioner) treating the  beneficiary must document in the beneficiary's medical record that the beneficiary is a diabetic.   *When a claim contains a DSMT HCPCS code and the associated units cause the total time for any follow -up year to exceed 2 hours, a CWF error will set.  300.4 - Coverage Requirements for Individual Training  (Rev. 72, Issued:  05- 25-07; Effective:  07 -01-07; Implementation:  07- 02-07)  Medicare covers training on an individual basis for a Medicare beneficiary under any of the following conditions:    No group session is available within 2 months of the date the training is ordered;    The beneficiarys physician (or qualified non -physician practitioner) documents in the beneficiarys medical record that the beneficiary has special needs resulting from conditions, such as severe vision, hearing or language  limitations or other such special conditions as identified by the treating physician or non- physician practitioner, that will hinder effective participation in a group training session; or    The physician orders additional insulin training.    The need for individual training must be identified by the physician or non -physician practitioner in the referral.