Effective Date: October 14, 2019

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

Scope:
Products included:

• NJ FamilyCare/Medicaid Plan
• Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP)

Definitions:

• Diagnosis Code Z13.1: Encounter for screening for diabetes mellitus
• Modifier –TS: Follow up service

Policy:
Patients Not Diagnosed As Pre-Diabetic:
Horizon NJ Health shall limit screening services, when billed with ICD-10 code Z13.1 (Encounter for screening for diabetes mellitus), to one (1) test per year for patients that have not been diagnosed as pre-diabetic, or have never been tested.

Patients Diagnosed as Pre-Diabetic:
Horizon NJ Health shall limit screening services to one (1) 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 NJ Health 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 NJ Health 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.

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

• Benefit Limitations
• The terms of any applicable provider participation agreement;
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
• Medical necessity; and
• Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.

References:

Medicare Claims Processing Manual, Chapter 18- Preventive and Screening Services cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c18.pdf

Medicare Prescription Drug Improvement and Modernization Act of 2003 govinfo.gov/content/pkg/PLAW-108publ173/pdf/PLAW-108publ173.pdf

American Medical Association, Current Procedural Terminology (CPT®) Professional Edition and associated publications and services