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LCD
ID Number
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L1406
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LCD
Title
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Patient
Education
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Contractor's
Determination Number
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1406
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AMA
CPT / ADA
CDT Copyright Statement
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CPT codes,
descriptions and other data only are copyright 2007 American Medical
Association (or such other date of publication of CPT). All Rights
Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology,
(CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. © 2002,
2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
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CMS
National Coverage Policy
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Section 4105 of
Balanced Budget Act 1997: Diabetes education: This section allows for
coverage of diabetic education/self-management training when all conditions
are met.
Title XVIII of the Social Security Act, Section 1862 (a)(1)(A).
This section excludes coverage of items or services that are not reasonable
and necessary for the diagnosis or treatment of illness or injury or to
improve the functioning of a malformed body member.
Title XVIII of the Social Security Act, Section 1862 (a)(7).
This section prohibits Medicare payment for any expenses on items and
services incurred for routine physical examinations.
Title XVIII of the Social Security Act, Section 1833 (e). This section
prohibits Medicare payment for any claim that lacks the necessary
information to process the claim.
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Primary Geographic
Jurisdiction
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New
Jersey
Tennessee
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Secondary Geographic
Jurisdiction
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Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
North Carolina
North Dakota
Nebraska
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
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Oversight
Region
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Region IV
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Original
Determination Effective Date
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For services performed
on or after 01/25/1995
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Original
Determination Ending Date
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Revision
Effective Date
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For services performed
on or after 07/26/2005
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Revision
Ending Date
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Indications
and Limitations of Coverage and/or Medical Necessity
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Patient education
consists of educational programs furnished by providers to Medicare
Beneficiaries as an integral part of a covered service for the treatment of
an illness or injury.
Reimbursement may be made for Patient Education if the education/program is
reasonable and necessary and also appropriate for the treatment of the
individual's illness or injury. Group education may be covered if plan is
individualized for each beneficiary. Examples of Patient Education that may
be considered coverable are:
1. Teaching patients to give themselves injections
2. Instruction on special diets
3. Teaching colostomy care
4. Administration of medical gases
5. Peritoneal dialysis (CCPD and/or CAPD) training
6. Diabetes outpatient self-management training
Programs designed to prevent illness through general instruction in
nutrition, exercise, or hygiene are not related to
the treatment of an illness or injury and are primarily preventative in
nature and therefore are not coverable. Preoperative teaching by nursing
done while a patient is awaiting a procedure is a routine nursing service
and is not separately billable. Education/instruction of long-term
diabetics who do not have a current medical management problem is not
considered reasonable and necessary and therefore is not coverable.
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Coverage
Topic
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Outpatient Hospital Services
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