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Diabetes Self-Management Education

The South Dakota Medical Assistance Program has a coverage policy for Diabetes Self-Management Education. This service is reimbursable when delivered to an eligible Medical Assistance recipient by a program certified by the American Diabetes Association or recognized by the South Dakota Department of Health.

The coverage guidelines are not intended to exclude individuals who have not received any prior diabetes education. Provider questions may be directed to 1-800-452-7691 or 605-773-3495.

Enroll in the Program

Medical providers must complete an application and agreement form in order to enroll in the Diabetes Management Education Program. The agreement establishes contractual relations with the provider to ensure the provider adheres to rules and regulations established by South Dakota administrative rule and codified law.

The following forms must be completed:

Coverage Guidelines

Outpatient diabetes self-management education is a covered service when one of the following conditions are met:

  1. The individual is a newly diagnosed diabetic, gestational diabetic, or has received no previous diabetes education.
  2. The individual demonstrates poor glycemic control as evidenced by glycated hemoglobin level greater than 2 percent above the upper limit of normal for the assay used.
  3. There is a change in the treatment regimen.
  4. There is documentation of acute episodes of severe hypoglycemia or hyperglycemia occurring in the past year.
  5. The individual is high risk based on the presence of at least one of the following: extremity, renal, or cardiac complications or diabetic retinopathy.
  6. Outpatient diabetes self-management education is limited to ten hours of comprehensive education and follow-up education sessions of two hours per year based upon assessment of need and documented physician order.

The provider of outpatient self-management education must maintain the following documentation:

  1. A copy of the physician order.
  2. A comprehensive plan of care documented in the medical record.
  3. Assessment of the individual education needs.
  4. Individual education plan.
  5. Evaluation of achievement of self-management goals.

Outpatient diabetes self-management education will be reimbursable when delivered by an American Diabetes Association or South Dakota Department of Health recognized program and a claim is submitted by an enrolled provider such as a hospital or clinic.

Diabetes self-management education is not separately reimbursable when:

  1. The individual is institutionalized and the training is not delivered in an out-patient setting.
  2. The individual has already received the maximum hours of comprehensive diabetes education.
  3. The individual receives this service in a Federally Qualified Health Center or a Rural Health Clinic.

Diabetes self-management education is also covered for individuals under the age of 21 when prescribed by a physician and referred by the primary care provider.

Claim Requirements

A claim for diabetes self-management education may be submitted by an enrolled Diabetes Education program that has been certified by the American Diabetes Association or the South Dakota Department of Health.

The claim must be submitted on a CMS 1500 form and must contain the following information:

  1. The recipient's full name as it appears on the medical assistance identification card.
  2. The recipient's medical assistance identification number from the recipient's medical assistance identification card.
  3. Third-party liability information required under Administrative Rules of South Dakota (ARSD) 67:16:26.
  4. Date of service.
  5. Place of service.
  6. Type of service (9).
  7. The provider's usual and customary charge. The provider may not subtract other third-party or cost-sharing payments from this charge.
  8. Units of service, ARSD 67:16:46:05.
  9. Diagnosis codes as contained in the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) adopted in ARSD 67:16:01:26.
  10. The provider's name, address, telephone number and Diabetes Education Program provider number.
  11. The signature of the provider or provider's representative and the date of signature.
  12. A separate claim form must be used for each recipient.
  13. Applicable South Dakota Medical Assistance procedure codes ARSD 67:16:46:05:

Payment for services covered under the provisions of this chapter is limited to the following:

  • G0108 Diabetes Education, Individual, each 30-minute unit - $18.00
  • G0109 Diabetes Education, Group, each 30-minute unit - $13.00
  • S9455 Diabetes Education, Follow-up, Group, each 60-minute unit - $25.00
  • S9460 Diabetes Education, Follow-up, Individual, each 60-minute unit - $35.00

Cost Sharing

Cost sharing for diabetes education services is $3 for each unit of service billed. Eligible Medical Assistance recipients under the age of 19 years or under the Home and Community Based Services program are not required to participate in the cost of medical care.