### Related CR ####
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Diabetes Screening & Definitions Update:
CY 2024 Physician Fee Schedule Final Rule
Related CR Release Date: June 21, 2024
Effective Date: January 1, 2024
Implementation Date: October 7, 2024
MLN Matters Number: MM13487 Revised
Related Change Request (CR) Number: CR 13487
Related CR Transmittal Number: R12694BP
&
R12694CP
Related CR Title: Expand Diabetes Screening and Diabetes Definitions Policy Update in the
Calendar Year 2024 Physician Fee Schedule Final Rule
What’s Changed: We clarified claims processing requirements for ICD-10-CM
diagnosis code Z13.1 and previously processed claims. Also, updated the web
addresses of the transmittals (pages 1-3). Substantive content changes are in
dark red.
Affected Providers
•
Physicians
• Suppliers
• Other providers billing Medicare Administrative Contractors (MACs) for services
provided to Medicare patients
Action Needed
Make sure your billing staff knows about:
• The revised definition of diabetes
• Revised diabetes screening frequency limitations
• Coverage of the Hemoglobin A1c (HbA1c) test for diabetes screening
Background
CR 13487 advises you of policy updates for diabetes screening and diabetes definitions resulting
from changes specified in the CY 2024 Physician Fee Schedule (PFS) Final Rule (88 FR 78818)
.
Medicare Program Policy Before January 1, 2024
• Tests: CMS covered 2 tests for diabetes screening, including:
MLN Matters: MM13487 Related CR 13487
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o The Fasting Plasma Glucose (FPG) test (HCPCS code 82947, Glucose;
quantitative, blood (except reagent strip)) when you bill with ICD-10-CM
diagnosis code Z13.1
o The Post Glucose Challenge Test, also called the Glucose Tolerance Test
(GTT), HCPCS codes 82950 (Glucose; post glucose dose (includes glucose))
and 82951 (Glucose; tolerance tests (GTT), 3 specimens (includes glucose))
when you bill with ICD-10-CM diagnosis code Z13.1
Note: We covered the Hemoglobin A1C (HbA1c) test (HCPCS code 83036) for
purposes of diabetes management but not for diabetes screening.
• Frequency Limitations: We allowed 2 screening tests per CY if the patient was
previously diagnosed with prediabetes and 1 screening test per year for patients who
were previously tested but not diagnosed with prediabetes, or who were never tested.
Note: Prediabetes was defined in regulations as a condition of abnormal glucose
metabolism diagnosed using 1 of these criteria:
o A fasting glucose level of 100-125 mg/dL
o A 2-hour post-glucose challenge of 140-199 mg/dL
The term prediabetes includes these conditions:
o Impaired fasting glucose
o Impaired glucose tolerance
• Definition: The regulatory definition of diabetes for purposes of diabetes screening,
Medical Nutrition Therapy (MNT), and Diabetes Outpatient Self-Management Training
Services (DSMT) included a clinically specific test-based definition for diabetes. The
regulatory text read: Diabetes means diabetes mellitus, a condition of abnormal glucose
metabolism diagnosed using these criteria:
o A fasting blood sugar greater than or equal to 126 mg/dL on 2 different occasions
o A 2-hour post-glucose challenge greater than or equal to 200 mg/dL on 2
different occasions
o A random glucose test over 200 mg/dL for a person with symptoms of
uncontrolled diabetes
• Find more information on:
o Diabetes screening coverage at 42 CFR 410.18
o MNT coverage at 42 CFR 410.132
o DSMT coverage at 42 CFR 410.140
Policy Updates Effective January 1, 2024
• Tests: Medicare now covers the HbA1c test for diabetes screening in addition to the
FPG and GTT tests already authorized for diabetes screening when you bill with ICD-10-
CM diagnosis code Z13.1.
MLN Matters: MM13487 Related CR 13487
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Note: Patient coinsurance and deductible don’t apply to the HbA1c tests you provide for
diabetes screening because the U.S. Preventive Services Task Force, August 2021
Final Recommendation Statement on Diabetes Screening includes the HbA1c test
(Grade B).
• Frequency Limitations: We simplified diabetes screening frequency limitations to not
more than 2 times within the 12-month period following the date of the most recent
diabetes screening test of that patient. Medicare no longer distinguishes diabetes
screening frequency limitations based on a prior diagnosis of prediabetes. We removed
the regulatory definition of prediabetes from Medicare regulations.
• Definitions: We simplified the regulatory definition of diabetes for purposes of diabetes
screening, MNT, and DSMT. It’s now: Diabetes means diabetes mellitus, a condition of
abnormal glucose metabolism.
CR 13487 has 2 transmittals:
• Transmittal R12694BP updates Section 300.1 of the Medicare Benefit Policy Manual,
Chapter 15
• Transmittal R12694CP updates Section 300 of the Medicare Claims Processing Manual,
Chapter 4
MACs won’t search their files for previously processed claims with dates of service on or after
January 1, 2024 unless you bring them to their attention.
More Information
We issued CR 13487 to your MAC as the official instruction for this change.
For more information, find your MAC’s website
.
Document History
Date of Change
Description
June 25, 2024
We clarified claims processing requirements for ICD-10-CM diagnosis
code Z13.1 and previously processed claims. Also updated the web
addresses of the transmittals (pages 1-3). Substantive content changes
are in dark red.
May 3, 2024
Initial article released.
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