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Diabetic Screening Services

Reimbursement Policy:
Diabetic Screening Services

Effective Date:
February 25, 2019

Purpose:
Provide guidelines for frequency of Diabetic Screening Services when appropriately billed by professional providers.

Scope:
All products are included, except

  • Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
  • COB
  • ITS Home In-Network
  • FEP
  • SHBP non MA

All Insured Individual, Commercial medical plans, and Medicare Advantage Plans, are included.

ASO accounts will be included as an Opt-In option for additional claims editing on an account-by-account basis

Policy:
Patients Not Diagnosed As Pre-Diabetic: In accordance with CMS’ Medicare Prescription Drug Improvement and Modernization Act of 2003, Horizon BCBSNJ shall limit screening services, when billed with ICD-10 code Z13.1 (Encounter for screening for diabetes mellitus), to one test per year for patients that have not been diagnosed as pre-diabetic, or have never been tested.

Patients Diagnosed as Pre-Diabetic: In accordance with CMS’ Medicare Prescription Drug Improvement and Modernization Act of 2003, Horizon BCBSNJ shall limit screening services to one test every six (6) months, when billed with ICD-10 code Z13.1 and appended with modifier TS, for patients that have been diagnosed as pre-diabetic.

Procedure:
For Non- Pre Diabetic Screening Services, Horizon BCBSNJ shall deny diabetes screening tests when billed with a diagnosis code Z13.1 and when billed more than once per year.

For Pre- Diabetic Screening services, Horizon BCBSNJ shall deny diabetes screening tests billed with a diagnosis code Z13.1 and appended with modifier TS when another diabetic screening test with the same diagnosis and modifier has been billed in the previous six (6) months.

No additional reimbursement will be made if the provider is capitated or the reimbursement structure for that provider is a global fee.

In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.

In instances where the provider is not participating, member liability shall be up to the provider’s charge.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

  • Group or Individual benefit
  • Provider Participation Agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
  • Mandated or legislative required criteria will always supersede.

CPT® is a registered trademark of the American Medical Association.

Policy 118_v1.0_01222018