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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

Diabetes-Related ServicesFACT SHEET

The summary of information presented in this factsheet is intended for Medicare Fee-For-Service

physicians, providers, suppliers, and other health careprofessionals who furnish or provide referrals for and/or le claims for the Medicare-covered preventivebenets discussed in this fact sheet.

DIABETES AND PRE-DIABETES

Diabetes Mellitus

Diabetes (diabetes mellitus) is dened as acondition of abnormal glucose metabolism usingthe following criteria:

A fasting blood glucose greater than or equal to126 mg/dL on two different occasions;

A 2-hour post-glucose challenge greater than orequal to 200 mg/dL on two different occasions; or

A random glucose test over 200 mg/dL for aperson with symptoms of uncontrolled diabetes.

Pre-diabetesPre-diabetes is a condition of abnormal glucosemetabolism diagnosed from a previous fastingglucose level of 100-125 mg/dL or a 2-hour post-glucose challenge of 140-199 mg/dL. The termpre-diabetes includes impaired fasting glucoseand impaired glucose tolerance.

DIABETES SCREENING TESTS

Medicare provides coverage of diabetes screeningtests for beneciaries at risk for diabetes or thosediagnosed with pre-diabetes.

The diabetes screening blood tests covered byMedicare include:

A fasting blood glucose test; and

A post-glucose challenge test; not limited to

an oral glucose tolerance test with a glucose

challenge of 75 grams of glucose for non-pregnanadults; or

a 2-hour post-glucose challenge test alone.

Coverage InformationTo be eligible for the diabetes screening tests,beneciaries must have any of the followingrisk factors:

Hypertension;

Dyslipidemia;

Obesity (a body mass index greater than orequal to 30kg/m2);

Previous identication of an elevated

impaired fasting glucose or glucose

tolerance.

ICN 006840 May 2011

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OR

At least two of the following characteristics:

Overweight (a body mass index greater than 25

but less than 30 kg/m2);

A family history of diabetes;

Age 65 or older; or

A history of gestational diabetes mellitus, or

delivery of a baby weighing greater than 9 pounds.

Medicare provides coverage for diabetes screeningtests with the following frequency:

Beneficiaries diagnosed with pre-diabetesMedicare provides coverage for a maximum of twodiabetes screening tests within a 12-month period(but not less than 6 months apart) for beneciariesdiagnosed with pre-diabetes.

Beneficiaries previously tested but not diagnosed

as pre-diabetic or who have never been testedMedicare provides coverage for one diabetesscreening test within a 12-month period (i.e., at least11 months have passed following the month in whichthe last Medicare-covered diabetes screening testwas performed) for beneciaries who were previouslytested and were not diagnosed with pre-diabetes, orwho have never been tested.

Medicare provides coverage for the diabetesscreening tests as a Part B benet. The beneciarywill pay nothing (there is no coinsurance or copaymentand no Medicare Part B deductible for this benet).

NOTE: The diabetes screening benet covered byMedicare is a stand-alone billable service separatefrom the Initial Preventive Physical Examinationand does nothave to be obtained within a certaintime frame following a beneciarys MedicarePart B enrollment.

DIABETES SELF-MANAGEMENTTRAINING (DSMT)

Medicare provides coverage of DSMT services for

beneciaries who have been recently diagnosedwith diabetes, were determined to be at risk forcomplications from diabetes, or were previouslydiagnosed with diabetes before meeting Medicareeligibility requirements and have since become eligiblefor coverage under the Medicare Program.

Medicare covers DSMT services when a certiedprovider who meets certain quality standardsfurnishes these services. DSMT services areintended to educate beneciaries in the successful

self-managementof diabetes. A qualiedDSMT program includes thefollowing services:

Instruction in self-monitoring ofblood glucose,

Education about diet and exercise,

An insulin treatment plan developedspecically for insulin-dependent

beneciaries, and

Motivation for beneciaries to use the skills forself-management.

Medicare provides coverage of DSMT services onlyif the treating physician or treating qualied non-physician practitioner managing the beneciarysdiabetic condition certies that DSMT services areneeded. The referring physician or qualied non-physician practitioner must maintain a plan of care inthe beneciarys medical record and documentationsubstantiating the need for training on an individualbasis when group training is typically covered, ifso ordered.

Coverage for DSMT services is provided as aMedicare Part B benet. Both the coinsurance orcopayment and the Medicare Part B deductible apply.The Medicare Part B deductible does not apply toFederally Qualied Health Centers.

NOTE: The DSMT program must be accredited asmeeting quality standards by a Centers for Medicare& Medicaid Services (CMS)-approved nationalaccreditation organization. Currently, CMS recognizesthe American Diabetes Association, the American

Association of Diabetes Educators, and the IndianHealth Service as approved national accreditationorganizations. Programs without accreditation by aCMS-approved national accreditation organization arenot covered.

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MEDICAL NUTRITION THERAPY (MNT)

Medicare provides coverage of MNT for beneciariesdiagnosed with diabetes or renal disease (except forthose receiving dialysis).

Renal DiseaseFor the purpose of this benet, renal disease meanschronic renal insufciency or the medical condition

of a beneciary who has been discharged from thehospital after a successful renal transplant within thelast 36 months. Chronic renal insufciency meansa reduction in renal function not severe enoughto require dialysis or transplantation [GlomerularFiltration Rate (GFR) 13-50 ml/min/1.73m2].

Medicare-Covered MNT ServicesMedicare provides coverage of MNT services whenthe following general coverage conditions are met:

The beneciary has diabetes or renal disease;

The treating physician* provides a referral andindicates a diagnosis of diabetes or renal disease;

The number of hours covered in an episodeof care may not be exceeded unless a second

referral is received from the treating physician*;

The services provided are either on an individual

or group basis without restrictions;

The services are provided by a registered dietitian,or a nutrition professional who meets the provider

qualication requirements, or a grandfathered

dietitian or nutritionist who was licensed as of

December 21, 2000;

The services are provided within the same timeperiod and for the maximum number of hours

allowed under each benet**;

The beneciary, with a diagnosis of diabetes, hasreceived DSMT and is also diagnosed with renal

disease in the same episode of care; and

The beneciary has a change in medicalcondition, diagnosis or treatment.

* A treating physician means the primary carephysician or specialist coordinating care for thebeneciary with diabetes or renal disease. Non-

physician practitioners cannot make referrals forthis service.

** DSMT and MNT services can be provided withinthe same time period, and the maximum number ofhours allowed under each benet is covered. Theonly exception is that DSMT and MNT may not be

provided on the same day to the same beneciary.They are different benets and require separatereferrals from physicians.

This benet provides 3 hours of one-on-one MNTservices for the rst year and 2 hours of coverageeach year for subsequent years.

Based on medical necessity, additional hours

may be covered if the treating physician ordersadditional hours of MNT based on a change in

medical condition, diagnosis, or treatment regimen

Medicare provides coverage of MNT as a MedicarePart B benet. Both the coinsurance or copayment

and the Medicare Part B deductible apply. For

dates of service on or after January 1, 2011, both

the coinsurance or copayment and deductible

are waived.

COVERED SUPPLIES AND OTHER SERVICES

FOR BENEFICIARIES WITH DIABETES

Medicare provides limited coverage, based onestablished medical necessity requirements, for thefollowing diabetes supplies:

Blood glucose self-testing equipment andassociated accessories;

Therapeutic shoes, including:

One pair of depth-inlay shoes and three

pairs of inserts; or

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One pair of custom-molded shoes (including

inserts), if the beneciary cannot wear depth-

inlay shoes because of a foot deformity,

and two additional pairs of inserts within the

calendar year; and

Insulin pumps and the insulin used in the pumps.

NOTE: In certain cases, Medicare may also payfor separate inserts or shoe modications instead

of inserts.

Medicare provides coverage of the following servicesfor beneciaries with diabetes:

Foot care;

Glaucoma screening;

Hemoglobin A1c tests;

Inuenza and pneumococcal immunizations;

Routine costs, including immunosuppressive drugs,cell transplantation, and related items and services

for pancreatic islet cell transplant clinical trials; and

Retinal eye exams for diabetic retinopathy.*

* Retinal eye exams for diabetic retinopathy may becovered as a medically necessary diagnostic examfurnished to beneciaries diagnosed with diabetes.

RESOURCES

The Centers for Medicare & Medicaid Services (CMS)has developed a variety of educational resourcesas part of a broad outreach campaign to promoteawareness and increase utilization of preventive

services covered by Medicare.

For more information about coverage, coding, billing,and reimbursement of Medicare-covered preventiveservices and screenings, visit http://www.cms.gov/MLNProducts/35_PreventiveServices.aspon theCMS website.

MEDICARE LEARNING NETWORK (MLN)

The Medicare Learning Network (MLN), a registeredtrademark of CMS, is the brand name for ofcial CMS

educational products and information for MedicareFee-For-Service Providers. For additional information,visit the MLNs web page at http://www.cms.gov/MLNGenInfo on the CMS website.

Your feedback isimportant to us andwe use your suggestions tohelp us improve our educationalproducts, services and activitiesand to develop products, servicesand activities that better meet youreducational needs. To evaluate MedicareLearning Network (MLN) products, services

and activities you have participated in, received,or downloaded, please go to http://www.cms.gov/MLNProducts and click on the link calledMLN Opinion Page in the left-hand menu andfollow the instructions.

Please send your suggestions related to MLN producttopics or formats to MLN@cms.hhs.gov.

BENEFICIARY-RELATED INFORMATION

The ofcial U.S. Government website for peoplewith Medicare is located on the web at http://www.

medicare.gov, or more information can be obtainedby calling 1-800-MEDICARE (1-800-633-4227). TTYusers should call 1-877-486-2048.

This fact sheet was current at the time it was publishedor uploaded onto the web. Medicare policy changesfrequently so links to the source documents have been

provided within the document for your reference.

This fact sheet was prepared as a service to thepublic and is not intended to grant rights or imposeobligations. This fact sheet may contain references or

links to statutes, regulations, or other policy materials.The information provided is only intended to be ageneral summary. It is not intended to take the placeof either the written law or regulations. We encouragereaders to review the specic statutes, regulations,and other interpretive materials for a full and accuratestatement of their contents.

Official CMS Information for

Medicare Fee-For-Service Providers

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