Continuous Glucose Monitor (CGM) Supply Allowance Calculator

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The supply allowance, HCPCS codes K0553, A4239 or A4238, is billed as one unit of service per 30 days.

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Glucose Monitors

Coverage

Documentation

Different Types of CGMS (Not all Inclusive)

  Stand-alone Integrated into Insulin Infusion Pump
(CGM Component is bolded)
Non-adjunctive CGMs
  • Dexcom G6
  • Abbott Freestyle Libre
  • Abbott Freestyle Libre 2
  • Tandem t:slim X2 insulin pump + Abbott Freestyle Libre or Abbott Freestyle Libre 2
  • Tandem t:slim X2 insulin pump + Dexcom G6
Adjunctive CGMs NOT COVERED BY MEDICARE
  • Minimed Guardian Connect
  • Freestyle Libre 3
(Not classified as DME, no monitor)
  • Medtronic Minimed 630G + Minimed Guardian 3 CGM Sensor
  • Medtronic Minimed 670G + Minimed Guardian 3 CGM Sensor
  • Medtronic Minimed 770G + Minimed Guardian 3 CGM Sensor

 

Reviews/Audits

  • Medical Review - View notifications/findings of pre/post claim reviews completed by Noridian Medical Review

Continuous Glucose Monitors (CGM) procedure code update:

  • New HCPCS Codes (Effective for DOS on or after 01/01/2023)
    • A4239 - Supply allowance for non-adjunctive, non-implanted continuous glucose monitor (CGM), includes all supplies and accessories, 1month supply = 1 unit of service
    • E2103 - Non-adjunctive, non-implanted continuous glucose monitor or receiver
  • Deleted Codes (Effective for DOS prior to 01/01/2023)
    • K0553 - Supply allowance for therapeutic CGM device
    • K0554 - CGM receiver/monitor

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Topic Details

Continuous Glucose Monitor (CGM)

Billing Monthly Supply Allowance

When CGM codes are covered, the related supply allowance codes are also covered.

CGM codes - K0554, E2103, and E2102

Supply allowance codes - K0553, A4239, and A4238

The supply allowance (codes K0553, A4239, and A4238) are billed as 1 Unit of Service (UOS) per thirty (30) days. Only one (1) UOS of code K0553, A4239, or A4238 may be billed to the DME MACs at a time. Billing more than 1 UOS per 30 days of code K0553, A4239, or A4238 will be denied as not reasonable and necessary.

Because CGM supplies sometimes come as a 14-day supply kit, below is an example of billing the monthly supply allowance.

Example:

  • First month - Provide three kits of supplies during month: 3 x 14-day supply = 42-day supply - Bill one supply allowance fee. Will have 12 days of supplies left over for next month
  • Second month - Provide two kits of supplies during month: 2 x 14-day supply = 28-day supply - Bill one supply allowance fee. Will have 10 days of supplies left over for next month
  • Third month - Provide two kits of supplies during month: 2 x 14-day supply = 28-day supply - Bill one supply allowance fee. Will have 8 days of supplies left over for next month
  • Fourth month - Provide two kits of supplies during month: 2 x 14-day supply = 28-day supply - Bill one supply allowance fee. Will have 6 days of supplies left over for next month

See the Continuous Glucose Monitor: Provide Supplies for a Calendar Month MLN Connects for more details.

Continuous Glucose Monitor (CGM) Supply Allowance

The supply allowance (K0553, A4239, or A4238) is billed as one unit of service per 30 days. Billing more than one unit in 30 days will be denied as not reasonable and necessary.

  • K0553, A4239 - Supply allowance for non-adjunctive, non-implanted continuous glucose monitor (CGM), includes all supplies and accessories, 1month supply = 1 unit of service
  • A4238 - Supply Allowance for Non-Therapeutic (Adjunctive) CGM

Diabetic Supplies Used with Blood Glucose Monitor (BGM) and Continuous Glucose Monitor (CGM)

  • BGM supply HCPCS codes, K0553, A4239, or A4238 requires one of the below.
    • Beneficiary owned equipment be on file with Medicare Fee-for-service for HCPCS E0607, E2100, E2101, K0554, E2103, or E2102
      OR
    • A narrative on the claim line in item 19 of CMS-1500 Claim Form or the 2400/NTE segment of an electronic claim indicating beneficiary owned HCPCS E0607, E2100, E2101, K0554, E2103, or E2102 and its approximate purchase date
      • Example: Beneficiary owned E0607. Purchased 09/15/2021

If there is no glucose monitor in the Medicare claims history or the narrative is missing, the claim will deny as missing the equipment that requires the supply.

Resolving Denials

If a denial is received with Reason Code 16, Remark Code M124 that states: missing indication of whether the patient owns the equipment that requires the part or supply, the supplier must provide that information to Medicare to place on file. This can be accomplished in the following ways:

Once the beneficiary-owned item is placed on file, subsequent supply claims do not require a narrative.

Diabetic Supplies and Accessories Used with CGM K0554 or E2103

Diabetic Supplies and Accessories Used with CGM K0554 or E2103 must be billed to the DME MAC with HCPCS K0553 or A4239. The supply allowance includes all items necessary for the use of the device and includes, but is not limited to: CGM sensor, CGM transmitter, home BGM and related BGM supplies (test strips, lancets, lancing device, calibration solutions) and batteries. One unit of service equals a one-month supply to be used with the CGM. These supplies shall not be billed individually or with a National Drug Code (NDC). Suppliers should work with their billing/software vendors to ensure individual supplies/codes are consolidated into HCPCS K0553 or A4239. See CMS Medicare Learning Network (MLN) Matters (MM) 10013 for details.

 

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Last Updated Wed, 25 Jan 2023 15:57:11 +0000

The below are topic specific articles which have been published to "Latest Updates" and sent out in Noridian emails within the past two years. Exclusions to this include time sensitive related announcements such as: Noridian and CMS educational events, Ask-the-Contractor Teleconferences and claims processing downtime.

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