Reimbursement & Coding for Prediabetes Screening

Medicare recommends and provides coverage for diabetes screening tests through Part B Preventive Services for beneficiaries at risk for diabetes or those diagnosed with prediabetes. For more about preventive services, see Medicare’s Preventive Services (PDF, 106 KB) chart, which includes information about "Diabetes Screening," "Diabetes Self-Management Training," and "Annual Wellness Visit." The Quick Reference Information: The ABCs of Providing the Annual Wellness Visit (PDF, 3.03 MB) provides additional information about this benefit.

When filing claims to Medicare for diabetes screening tests*, the following Healthcare Common Procedure Coding System (HCPCS) codes, Current Procedural Terminology (CPT) codes, and diagnosis codes must be used to ensure proper reimbursement.

Table 1: HCPCS/CPT Codes and Descriptors

Table 2: Diagnosis Code and Descriptor

Print/view this table and information as PDF (PDF, 68 KB)

Important Note: The Centers for Medicare and Medicaid Services (CMS) monitors the use of its preventive and screening benefits. By correctly coding for diabetes screening and other benefits, providers can help CMS more accurately track the use of these important services and identify opportunities for improvement. When submitting a claim for a diabetes screening test, it is important to use diagnosis code V77.1 and the “TS” modifier on the claim as indicated in Table 2 above, along with the correct HCPCS/CPT code (Table 1), so that the provider/supplier can be reimbursed correctly for a screening service and not for another type of diabetes testing service.

Medicare beneficiaries who have any of the following risk factors for diabetes are eligible for this screening benefit:

• Hypertension
• Dyslipidemia
• Obesity (a body mass index equal to or greater than 30 kg/m2)
• Previous identification of elevated impaired fasting glucose or glucose tolerance

or

Medicare beneficiaries who have a risk factor consisting of at least two of the following characteristics are eligible for this screening benefit:

• Overweight (a body mass index greater than 25, but less than 30 kg/m2)
• A family history of diabetes
• Age 65 years or older
• A history of gestational diabetes mellitus or of delivering a baby weighing greater than 9 pounds

*Learn more about Medicare’s coverage of diabetes screening tests.

Transition to ICD-10 codes

The Department of Health and Human Services (HHS) has mandated that the ICD-9-CM code sets used to report medical diagnoses and procedures will be replaced with ICD-10 code sets. Only a handful of countries, including the United States, have not already adopted ICD-10 as their standard for reporting. The transition to ICD-10 is required for everyone covered by the Health Insurance Portability and Accountability Act (HIPAA). The change to ICD-10 does not affect CPT coding for outpatient procedures and physician services. The ICD-10 code for prediabetes is R73.09. For more information about the transition to ICD-10 codes, visit the CMS ICD-10 website at www.cms.gov/Medicare/Coding/ICD10/index.html.

An emerging opportunity: Intensive Behavioral Therapy for obesity

Effective in 2011, Medicare covers intensive behavioral counseling and behavioral therapy to promote sustained weight loss for Medicare beneficiaries. Many Medicare patients with prediabetes are eligible for this benefit. To be compensated by Medicare, the professional who is offering the counseling must be a primary health care provider delivering the counseling interventions in a health care setting. A brief overview of this benefit is provided. To learn more, see Medicare’s guide for Intensive Behavioral Therapy (IBT) for Obesity.

Components of IBT:

• Screening for obesity in adults using measurement of BMI
• Dietary (nutritional) assessment
• Intensive behavioral counseling and behavioral therapy to promote sustained weight loss through high intensity interventions on diet and exercise

Requirements for IBT:

• BMI ≥ 30 kg/m2
• Counseling provided by a qualified primary care physician or other primary care practitioner in a primary care setting
• Counseling must be consistent with the 5 A’s approach adopted by the U.S. Preventive Services Task Force.

Reimbursement for IBT:

• The HCPCS Code for IBT is G0447 for Face-to-face behavioral counseling for obesity, 15 minutes.
• Payment to the provider is currently being made on a fee-for-service basis, with Medicare covering up to 22 IBT encounters in a 12-month period:
  • One face-to-face visit every week for the first month
  • One face-to-face visit every other week for months 2–6
  • One face-to-face visit every month for months 7–12, if the beneficiary meets the 3 kg (6.6 pounds) weight loss requirement during the first 6 months

The beneficiary pays nothing (no coinsurance or copayment and no Medicare Part B deductible) for IBT for obesity if the provider accepts assignment.