Download Virginia Hospital Center

Virginia Hospital Center
Diabetes Education Program
Fax: (703)558-6655
call Dee Brown RN, CDE
or Fax: (703)558-2455
call Joanna Conroy, RD, CDE
Physician Order Form
Phone: (703)558-6269
Phone: (703)558-6811
________________________________________________________________________________________
PATIENT INFORMATION
___________________________
Patient’s Last Name
___________________________
First Name
_____________________________
Middle
Birth Date____________________ Medicare HIC#____________________ Male
Female
Address_____________________________ City________________ State_________ Zip Code___________
Home Phone___________________ Work Phone___________________ Other Contact Phone____________
Diabetes self-management training (DSMT) and medical nutrition therapy (MNT) are individual and complementary services to
improve diabetes care. For Medicare beneficiaries, both services can be ordered in the same year. Research indicates MNT
combined with DSMT improves outcomes.
REQUIRED DIAGNOSTIC CRITERIA for Medicare reimbursement
__________ Fasting Blood Glucose(≥126 mg/dl), Random BGM≥200 or 2 hr GTT≥200 Please attach laboratory data
DIABETES SELF-MANAGEMENT TRAINING
(DSMT)
Medicare: 10 hours initial DSMT in 12 month
period, plus 2 hours follow-up DSMT annually
Check type of training services and number of hours
requested:
Initial group DSMT: 10 hours or No. hr(s) requested
Follow-up DSMT:
2 hours or
No. hr(s) requested
Additional insulin training:
No. hr(s) requested
_________________________________________________
Patients with special needs requiring individual
DSMT
Check all special needs that apply:
Vision Hearing Physical Cognitive Impairment
Language limitations Other…………………………..
_________________________________________________
DSMT Content
All ten content areas, as appropriate
Monitoring diabetes
Diabetes as disease process
Psychological adjustment
Physical activity
Nutritional management
Goal setting problem solving
Medications
Prevent, detect and treat
Preconception/pregnancy
acute complications
management or gestational Prevent, detect and treat
diabetes management
chronic complications
DIAGNOSIS
Please send recent labs for patient eligibility & outcomes
monitoring
Type 1 uncontrolled
Type 1 controlled
Type 2 uncontrolled
Type 2 controlled
Gestational diabetes
Other……………
Complications/Comorbidities
Check all that apply:
Signature and UPN #________________________________
Hypertension
Neuropathy
Renal disease
Non-healing wound
Mental/affective disorder
Dyslipidemia
Stroke
Nephropathy
PVD
Retinopathy
CAD
Pregnancy
Obesity
Other……………..
MEDICAL NUTRITION THERAPY (MNT)
Medicare: 3 hours initial MNT in the first year of
diagnosis, plus two hours follow-up MNT annually.
Additional MNT hours available for change in medical
condition, treatment and/or diagnosis.
*Check the type of MNT and /or number of additional hours
requested:
Initial MNT
Annual follow-up MNT
CURRENT DIABETES MEDICATIONS
Specify type, dose and frequency
..........................................................................................
..........................................................................................
PATIENT BEHAVIOR GOALS/PLAN CARE
..........................................................................................
DIAGNOSIS- Physicians select diagnosis, check the 5th digit
for Diabetes Mellitus
250.0 diabetes w/o complication ___0____1____2___3
250.1 diabetes w/ketoacidosis ____0____1____2____3
250.2 diabetes w/hyperosmolarity____0____1____2____3
250.3 diabetes w/other coma____0____1____2____3
250.4 diabetes w/renal manifestations ____0____1____2____3
250.5 diabetes w/ophthalmic manifestations____0____1____2____3
250.6 diabetes w/neurological manifestations ____0____1____2____3
250.7 diabetes w/peripheral circulatory disorders ____0____1____2___3
250.8 diabetes w/other specified manifestations ____0____1____2____3
250.9 diabetes w/unspecified complication ____0____1____2____3
*0 – type II or unspecified type, not stated as uncontrolled
1 – type I (juvenile type), not stated as uncontrolled
2–type II or unspecified type, uncontrolled ( 3-type1uncontrolled)
Date:______________________________________