Article Detail - JD DME

Outlined below are the principal changes to the DME MAC Local Coverage Determinations (LCDs) and Policy Articles (PAs) that have been revised and posted. The policies included are Glucose Monitors and External Infusion Pumps. Please review the entire LCDs and related PAs for complete information.

External Infusion Pumps

LCD

Revision Effective Date: 01/01/2023
COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:
Removed: Language describing “therapeutic,” “non-adjunctive,” “non-therapeutic,” and “adjunctive” terms and term usage
Removed: HCPCS code K0554
Added: HCPCS code E2103

12/29/2022: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because the revisions are non-discretionary updates to CMS HCPCS coding determinations.

PA

Revision Effective Date: 01/01/2023
CODING GUIDELINES:
Added: “A4238**, A4239**” to table describing associated codes with pump codes for pump code row E0784
Added: “**For E0784 pumps, either A4238 or A4239 may be billed if used in conjunction with an integrated adjunctive or non-adjunctive CGM, respectively.” after table describing associated codes
Revised: Billing direction dates for HCPCS codes K0554 and K0553
Added: Billing direction for HCPCS codes E2103 and A4239 on or after January 1, 2023
Removed: Language describing “non-therapeutic”
Added: “NON-IMPLANTED” to the description of CGM code E2102 and CGM supply code A4238

12/29/2022: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Glucose Monitors

LCD

Revision Effective Date: 01/01/2023
CONTINUOUS GLUCOSE MONITORS (CGM):
Removed: Statement regarding general CGM term referring to both therapeutic/non-adjunctive and non-therapeutic/adjunctive
Removed: “therapeutic” and “non-therapeutic”
Removed: HCPCS codes K0554 and K0553
Added: HCPCS codes E2103 and A4239
REFILL REQUIREMENTS:
Removed: HCPCS code K0553
Added: HCPCS code A4239
HCPCS CODES:
Revised: Long descriptor for HCPCS code E2102 in Group 1 Codes
Added: HCPCS code E2103 to Group 1 Codes
Removed: HCPCS code K0554 from Group 1 Codes
Revised: Long descriptor for HCPCS code A4238 in Group 2 Codes
Added: HCPCS codes A4239, A9277, A9276 and A9278 to Group 2 Codes
Removed: HCPCS codes A9279 and K0553 from Group 2 codes

12/29/2022: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because they are non-discretionary updates to CMS HCPCS coding determinations.

PA

Revision Effective Date: 01/01/2023
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Added: “(non-adjunctive)” to coverage of claims with dates of service on or after January 12, 2017
Removed: “therapeutic” and “non-therapeutic” from testing language
Added: HCPCS code A4239 to supply allowance language
Removed: HCPCS code K0553 from supply allowance language
Added: HCPCS code E2103 to coverage of a CGM supply allowance language
Removed: HCPCS code K0554 from coverage of a CGM supply allowance language
Removed: HCPCS code K0554 from the coding verification review by the PDAC language
Added: HCPCS code E2103 to the coding verification review by the PDAC language
Added: HCPCS codes A9276, A9277 and A9278 to the codes that must be utilized for products that do not meet the DME benefit category
MODIFIERS:
Removed: HCPCS codes K0553 and K0554 from the CGM language
Added: HCPCS codes E2103 and A4239 to the CGM language
Removed: HCPCS code K0554 from the CG modifier instructions for when all of the CGM criteria are met
Added: HCPCS code E2103 to the CG modifier instructions for when all of the CGM criteria are met
Removed: HCPCS code K0554 from the KF modifier instructions regarding CGMs classified by the Food & Drug Administration as Class III devices
Added: HCPCS code E2103 to the KF modifier instructions regarding CGMs classified by the Food & Drug Administration as Class III devices
CODING GUIDELINES:
Added: “through December 31, 2022” to claims with dates of service on or after July 1, 2017, that must be billed with K0554 and K0553
Added: “For claims with dates of service on or after January 1, 2023, a non-adjunctive CGM must be billed with code E2103 and code A4239 for the supply allowance."
Added: HCPCS code E2103 to description of non-adjunctive CGM that meets DME benefit requirements
Added: HCPCS code A4239 to supply allowance language
Removed: HCPCS code K0553 from supply allowance language
Added: HCPCS code A4239 to delivery and billing language
Removed: HCPCS code K0553 from delivery and billing language
Added: Billing instructions for dates of service prior to April 1, 2022, and on or after January 1, 2023, for HCPCS codes A9276 and A9277 to describe supplies used with a CGM that does not meet the definition of DME
Added: Instructions not to bill HCPCS codes A9276 and A9277 for supplies used with a non-adjunctive CGM (E2103) or adjunctive CGM supplies furnished in conjunction with an insulin infusion pump used as a CGM receiver
Added: Billing instructions to use HCPCS code A9279, for dates of service between April 1, 2022, through December 31, 2022, to describe any CGM system and/or related supplies that fail to meet the DME benefit requirement
Added: HCPCS code E2103 to “Column I”
Removed: HCPCS code K0553 from “Column I”
Removed: “Effective for claims with dates of service on or after 07/01/2017, the only products that may be billed using code K0554 are those that are specified in the PCL on the PDAC contractor web site.”

12/29/2022: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Note: The information contained in this article is only a summary of revisions to the LCDs and/or PAs. For complete information on any topic, you must review the LCDs and/or PAs.
With the update(s) listed above, Noridian would like to remind users how to find the policy that was previously effective. When billing, the supplier should follow guidance that was effective on the date of service. The below steps can be followed to find all previous policies:

1. Open the currently effective policy on the Medical Coverage Database (MCD)
   1. Links to the MCD can be found on the Active LCDs page on the Noridian website
      1. There is a link at the top of the Active LCD page that goes to a full list of the LCDs or PAs, depending on which link is selected OR
      2. There are direct links to all LCDs under the ‘LCD ID number and Effective Date’ column
2. Scroll down to the bottom of the policy
3. Find the section labeled Public Version(s)
4. Look for the link to the policy that was effective on the dates of service in question
5. Click on hyperlink to go to the policy