RETIRED - Continuous Glucose Monitors - Correct Coding and Billing - JA DME

Joint DME MAC Publication
Posted February 24, 2022

Background

On December 28, 2021, the Centers for Medicare & Medicaid Services (CMS) published a final rule in the Federal Register that, in part, addressed the classification and payment of continuous glucose monitors (CGMs) under the Medicare Part B benefit for durable medical equipment (DME). This rule expanded the classification of DME to a larger group of CGMs, regardless of whether the CGMs are non-adjunctive (can replace standard blood glucose monitors for treatment decisions) or adjunctive (do not replace standard blood glucose monitors for treatment decisions). As such, claims for adjunctive CGMs and related supplies and accessories with dates of service on or after the effective date of the final rule, February 28, 2022, can now be covered under the Part B DME benefit category when the system meets the DME definition.

Non-Adjunctive CGM Devices and Supplies

Existing HCPCS codes K0554 (RECEIVER (MONITOR), DEDICATED, FOR USE WITH THERAPEUTIC GLUCOSE CONTINUOUS MONITOR SYSTEM) and K0553 (SUPPLY ALLOWANCE FOR THERAPEUTIC CONTINUOUS GLUCOSE MONITOR (CGM), INCLUDES ALL SUPPLIES AND ACCESSORIES, 1 MONTH SUPPLY = 1 UNIT OF SERVICE) describe non-adjunctive CGM receivers and the associated monthly supplies and accessories. Suppliers may bill 1 unit of service (UOS) per thirty (30) days.

Adjunctive CGM Devices

There are no devices on the United States market that function as stand-alone adjunctive CGM devices. Current technology for adjunctive CGM devices operates in conjunction with an insulin pump.

Effective for claims with dates of service on or after April 1, 2022, CMS is creating the following HCPCS code to represent an adjunctive CGM device used in conjunction with an insulin pump:

E2102 ADJUNCTIVE CONTINUOUS GLUCOSE MONITOR OR RECEIVER

For claims with dates of service on or after April 1, 2022, suppliers must bill as a rental (RR) both E0784 (EXTERNAL AMBULATORY INFUSION PUMP, INSULIN) and E2102 to describe the rental of an insulin pump with integrated adjunctive CGM receiver functionality.

Effective for claims with dates of service February 28, 2022 through March 31, 2022, suppliers are required to bill miscellaneous HCPCS code E1399 (DURABLE MEDICAL EQUIPMENT, MISCELLANEOUS) for an adjunctive continuous glucose monitor or receiver until code E2102 becomes effective on April 1, 2022. Suppliers must bill as a rental (RR) both E0784 and E1399 to describe the rental of an insulin pump with integrated adjunctive CGM receiver functionality. When submitting a claim for E1399, suppliers must enter "adjunctive" in loop 2300 (claim note) and/or 2400 (line note), segment NTE02 (NTE01=ADD) of the ANSI X12N, version 5010A1 professional electronic claim format or in Item 19 of the paper claim form, so that the items can be identified as adjunctive CGM devices when processing the claim.

Suppliers are reminded that payment for E2102 (or E1399 for dates of service between February 28, 2022 and March 31, 2022), shall only be available for the CGM receiver function of a rented insulin infusion pump if the beneficiary does not already own a CGM receiver of any kind (either adjunctive or non-adjunctive) that is less than five years old and the beneficiary does not already own an insulin pump of any kind that is less than five years old. In addition, switching from an insulin pump without the CGM receiver feature to an insulin pump with the CGM receiver feature does not result in an interruption in the period of continuous use for the insulin pump or the start of a new 13-month rental cap period for the insulin pump for the beneficiary. The supplier shall transfer title of the equipment to the beneficiary on the first day following the end of the 13th month of use by the beneficiary. Regulations require the supplier of the insulin pump in month one to continue furnishing the pump for the remainder of the 13-month capped rental period or until medical necessity for the pump ends, whichever occurs sooner.

Adjunctive CGM Supplies and Accessories

Effective for claims with dates of service on or after April 1, 2022, CMS is creating the following HCPCS code to represent supplies used with an adjunctive CGM device that operates in conjunction with an insulin pump:

A4238 SUPPLY ALLOWANCE FOR ADJUNCTIVE CONTINUOUS GLUCOSE MONITOR (CGM), INCLUDES ALL SUPPLIES AND ACCESSORIES, 1 MONTH SUPPLY = 1 UNIT OF SERVICE

Effective for claims with dates of service on or after February 28, 2022 through March 31, 2022, suppliers are required to bill miscellaneous HCPCS code A9999 (MISCELLANEOUS DME SUPPLY OR ACCESSORY, NOT OTHERWISE SPECIFIED) for supplies and accessories used in conjunction with an insulin pump, which also performs the functions of an adjunctive continuous glucose monitor or receiver, until code A4238 becomes effective on April 1, 2022. Suppliers may bill 1 UOS per thirty (30) days. Code A9999 is all-inclusive; when used to bill for adjunctive CGM supplies and accessories it includes, but is not limited to, the CGM sensor, CGM transmitter and insertion devices. Code A9999 does not include payment for replacing the function of a home blood glucose monitor and related blood glucose monitor supplies (e.g., test strips, lancets, lancing device, and calibration solutions). A blood glucose monitor and/or related blood glucose monitor supplies are separately billable when used with an adjunctive CGM. When submitting a claim for A9999, suppliers must enter "adjunctive" in loop 2300 (claim note) and/or 2400 (line note), segment NTE02 (NTE01=ADD) of the ANSI X12N, version 5010A1 professional electronic claim format or in Item 19 of the paper claim form, so that the items can be identified as adjunctive CGM supplies and accessories when processing the claim.

Modifiers

Suppliers are reminded that the use of the CG, KF and KX modifiers are required, as appropriate, with the HCPCS codes describing both adjunctive and non-adjunctive CGM devices and the associated supply allowance codes.

Correct coding is an essential element for correct claim payment. The Pricing, Data Analysis and Coding (PDAC) contractor maintains a variety of resources to assist suppliers in determining the appropriate code for Medicare billing. For questions about correct coding, contact the PDAC HCPCS Helpline at (877) 735-1326 during the hours of 9:30 am to 5:00 pm ET, Monday through Friday. You may also visit the PDAC website to chat with a representative, or select the Contact Us button at the top of the PDAC website for email, FAX, or postal mail information.

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