Glucose Monitors - JA DME
Continuous Glucose Monitor (CGM) Supply Allowance Calculator
The supply allowance, HCPCS codes K0553 or A4238, is billed as one unit of service per 30 days.
- Home Blood Glucose Monitors National Coverage Determination (NCD)
- Glucose Monitors Local Coverage Determination (LCD)
- Glucose Monitors Policy Article
- Standard Documentation Requirements for All Claims Submitted to DME MACs
- Clinician Checklist Continuous Glucose Monitors [PDF] - Checklist to assist clinicians with coverage and documentation requirements
- Clinician Checklist Glucose Monitors and Related Supplies [PDF] - Checklist to assist clinicians with coverage and documentation requirements
- Continuous Glucose Monitors Documentation Checklist [PDF] - Checklist to ensure suppliers gather all required documentation
- Clinician Letter - Continued Medical Necessity [PDF] - Clinician directed letter that reminds them that ongoing need for and use of DMEPOS item must be documented in patient's medical record
- Clinician Letter - Glucose Monitors and Supplies [PDF] - Clinician directed letter that advises them as to what type of documentation is necessary in medical records to support payment of glucose monitors and related supplies
- Clinician Letter - Therapeutic Continuous Glucose Monitor (CGM) [PDF] - Clinician directed letter that advises them as to what type of documentation is necessary in medical records to support payment of glucose monitors and related supplies
- Glucose Monitors and Related Supplies Documentation Checklist [PDF] - Checklist to ensure suppliers gather all required documentation
- Medical Review - View notifications/findings of pre/post claim reviews completed by Noridian Medical Review
|Continuous Glucose Monitor (CGM)
Billing Monthly Supply Allowance
|When a CGM (codes K0554/E2102) are covered, the related supply allowance (codes K0553/A4238) are also covered.
The supply allowance (codes K0553/A4238) are billed as 1 Unit of Service (UOS) per thirty (30) days. Only one (1) UOS of code K0553 or A4238 may be billed to the DME MACs at a time. Billing more than 1 UOS per 30 days of code K0553 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.
|Continuous Glucose Monitor (CGM) Supply Allowance||The supply allowance (K0553 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.
|Diabetic Supplies Used with Blood Glucose Monitor (BGM) and Continuous Glucose Monitor (CGM)||Claims for dates of service (DOS) on/after March 1, 2020, for BGM supply HCPCS codes, K0553, or A4238 must require one of the below.
|Diabetic Supplies and Accessories Used with CGM K0554||Must be billed to the DME MAC with HCPCS K0553. 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. See CMS Medicare Learning Network (MLN) Matters (MM) 10013 for details.|
Last Updated Fri, 07 Oct 2022 20:09:09 +0000
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