Coding and Reimbursement

Coding and Reimbursement (Init)

Diabetes Reimbursement

Coverage, Coding and Payment

Medtronic has developed reimbursement information for your practice. This includes:

  • MiniMed 530G with Enlite system
  • Diabetes coverage, coding and payment resources
  • iPro®2 Professional CGM reimbursement

Professional CGM Reimbursement Guide (2013)Professional CGM Reimbursement Guide (2013) »

Professional CGM Reimbursement Guide (2014)CGM Reimbursement Quick Reference (2014)
 
Medtronic provides this information for your convenience only. It is not intended as a recommendation regarding clinical practice. It is always the provider’s responsibility to determine coverage and submit appropriate codes, modifiers, and charges for the services that were rendered. This document provides assistance for FDA approved or cleared indications. Where reimbursement is requested for a use of a product that may be inconsistent with, or not expressly specified in, the FDA cleared or approved labeling (e.g.,instructions for use, operator’s manual or package insert) consult with your billing advisors or payers for advice on handling such billing issues. Some payers may have policies that make it inappropriate to submit claims for such items or related service. Contact your Medicare contractor or other payer for interpretation of coverage, coding, and payment policies.
 

Coding & Reimbursement

ICD-9 Codes

 

Diagnosis codes are used by both physicians and hospitals to document the indication for the procedure or service performed.

The list below includes common ICD-9 diagnosis codes for Diabetes Mellitus.1

ICD-9 Description Fifth Digit
0 1 2 3
250.0 Diabetes mellitus without mention of complication type 2 or unspecified type, not stated as uncontrolled type 1 [juvenile type], not stated as uncontrolled type 2 or unspecified type, uncontrolled type 2 [juvenile type], uncontrolled
250.1 Diabetes with ketoacidosis
250.4 Diabetes with renal manifestations
250.5 Diabetes with ophthalmic manifestations
250.6 Diabetes with neurological manifestations
250.7 Diabetes with peripheral circulatory disorders
250.8 Diabetes with other specified manifestations
250.9 Diabetes with unspecified complication
1 Excludes 250.2 and 250.3 series for diabetes with coma

Coding & Reimbursement

HCPCS II Device Codes1

 

HCPCS II codes are a supplement to CPT® codes2. Although some HCPCS II codes are for procedures and services not classified in CPT, the majority of HCPCS II codes are for supplies, Durable Medical Equipment (DME), drugs, and medical devices. In many situations, CPT and HCPCS II codes must be used together to completely describe a service. In particular, CPT codes indicate the procedure performed and HCPCS II codes identify the specific device, supply, DME, or drug utilized in the procedure.These codes are used by the entity that purchased and supplied the medical device, DME, drug, or supply to the patient. For insulin pumps and Personal CGM, this is typically a DME supplier.

Product Code Description
Infusion Sets, Medicare weekly allowable code A4221 Supplies for maintenance of drug infusion catheter, per week (list drug separately)
Infusion Sets, non-needle A4230 Infusion set for external insulin pump, non-needle cannula type
Infusion Sets,needle A4231 Infusion set for external insulin pump, needle type
Pump reservoirs (also K0552) A4232 Syringe with needle for external insulin pump, sterile, 3 cc
Alcohol wipes A4245 Alcohol wipes, per box
Betadine swabs, per box A4247 Betadine or iodine swabs/wipes, per box
Adhesive, liquid, per ounce A4364 Adhesive, liquid or equal, any type, per oz.
Adhesive remover wipes, per 50 A4365 Adhesive remover wipes, any type, per 50
Tape A4450 Tape, nonwaterproof, per 18 sq in
Adhesive Remover A4455 Adhesive remover or solvent (for tape, cement or other adhesive), per oz.
Transparent Film, 16 sq. in or less A6257 Transparent film, sterile, 16 sq in or less, each dressing
Transparent Film, more than 16 sq. in A6258 Transparent film, sterile, more than 16 sq in but less than or equal to 48 sq in, each
Insulin Pump E0784 External ambulatory infusion pump, insulin
Pump reservoirs (also A4232) K0552 Supplies for external drug infusion pump, syringe type cartridge, sterile, each
Replacement battery, pump, silver oxide (MMT-104) K0601 Replacement battery for external infusion pump owned by patient, silver oxide, 1.5 volt, each
Insulin3 J1815 Injection, insulin, per 5 units
Insulin for insulin pump4 J1817 Insulin for administration through DME (i.e., insulin pump) per 50 units
Remote monitor A9279 Monitoring feature/device, stand-alone or integrated, any type, includes all accessories, components and electronics, not otherwise classified
1
Healthcare Common Procedure Coding System (HCPCS) Level II codes are maintained by the Centers for Medicare and Medicaid Services. More information can be found at: http://www.cms.hhs.gov/MedHCPCSGenInfo/01_Overview.asp#TopOfPage
2
CPT copyright 2013 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use
3
For Medicare, use J1817.
4
Only for insulin purchased under the DME benefit, such as for Medicare use.
 
 

Coding & Reimbursement

CPT/HCPCS II Codes for Provider Services Relating To Diabetes Management

 

Providers use CPT (and certain HCPCS II) codes for all services. Under Medicare's Resource-Based Relative Value Scale (RBRVS) methodology for physician payment, each code is assigned a point value, the relative value unit (RVU), which is then converted to a dollar payment amount. Many private payors use Medicare RVUs as the basis of their payment rates.

Service Code and Description Providers Who Can Perform the Service Payment Level1
Office visit to discuss insulin pump therapy initiation

Follow-up visits to discuss therapy modifications, etc.
Evaluation and Management (E/M) Codes:

99211 Office or other outpatient visit (only E/M code can be performed by a non-physician or mid-level practitioner)

99212-99215 Office or other outpatient visit

99354-99355 Proglonged service, office (must be billed with 99212-99215)
MD/DO

NP/PA
99211-99215: Medicare: $9-$144
Medicare RVU: 0.56-4.03

99354, 99355: Medicare: $100, $98
Medicare RVU: 2.80, 2.74
Medical management to start patients on insulin pump therapy (CSII) as it relates to insulin: carb ratios, basal rates, sick day management, insulin sensitivity for correction factor, etc. Diabetes Self Management Education and Training (DSMT) Codes:

G0108 Diabetes outpatient self-management training services, individual, per 30 minutes

G0109 Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes

Or 98960 Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient

98961; 2-4 patients 98962; 5-8 patients
CDEs/RDs/RNs in ADA-recognized programs G0108, G0109: Medicare: $53, $14
Medicare RVU: 1.49, 0.41

98960, 98961, 98962 Medicare: No Payment.
Medicare RVU: 0.77, 0.37, 0.27

Medicare does not pay for 98960- 98962, but does publish RVUs for these codes
Physician documentation of Face-to-face DME determination. G0454 Physician documentation of face-to-face visit for durable medical equipment determination performed by nurse practitioner, physician assistant or clinical nurse specialist MD/DO G0454:
Medicare: $8.85
Medicare RVU: 0.26
1
Medicare 2014 national average amount, rounded to the nearest full dollar amount. Includes 20% patient copayment amount. All RVUs are for services performed in the physician's office. These may not include potential payment reduction from US Government Sequestration. Source: Medicare Physician Fee Schedule 2014.
 
 

Coding & Reimbursement

Professional CGM

 

Service Code and Description Providers Who Can Perform the Service Payment Level1
CGM training, hookup, and download 95250 Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; sensor placement, hook-up, calibration of monitor, patient training, removal of sensor, and printout of recording

Qualified health care providers, consistent with state scope of practice laws
Medicare: $157
Medicare RVUs: 4.39
Interpretation of CGM data 95251 Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; interpretation and report

MD/DO

NP/PA
Medicare: $44
Medicare RVUs: 1.23
Pre-/post-CGM evaluation Evaluation and Management (E/M) Codes2:

99212-99215 Office or other outpatient visit

99354-99355 Proglonged service, office (must be billed with 99212-99215)
MD/DO

NP/PA
99212-99215

99211-99215: Medicare: $20- $144
Medicare RVU: 0.56-4.03

99354, 99355: Medicare: $100, $98
Medicare RVU: 2.80, 2.74
1
Medicare 2014 national average amount, rounded to the nearest full dollar amount. Includes 20% patient copayment amount. All RVUs are for services performed in the physician's office. These may not include potential payment reduction from US Government Sequestration. Source: Medicare Physician Fee Schedule 2014.
2
An office visit can only be billed separately when a CGM service is provided to the same patient on the same day if a medically necessary, separately identifiable evaluation and management service takes place in addition to the CGM service.