Coding and Reimbursement (Init)

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-10 diagnosis codes for Diabetes Mellitus.1

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.

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.

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.

1

Medicare 2017 national average amount, rounded to the nearest full dollar amount. Includes 20% patient copayment amount. All RVUs are for services performed in the non-facility setting. These may not include potential payment reduction from US Government Sequestration. Source: Medicare Physician Fee Schedule 2017.

1

Medicare 2018 national average amount, rounded to the nearest full dollar amount. Includes 20% patient copayment amount. All RVUs are for services performed in the non-facility setting. These may not include potential payment reduction from US Government Sequestration. Source: Medicare Physician Fee Schedule 2018.

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.