Coding and Reimbursement
Coding and Reimbursement (Init)
Diabetes Reimbursement

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Coding & Reimbursement
ICD-10
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
Complication Examples | ICD-10-CM Diabetes Diagnosis Code Options | |
---|---|---|
Type 1 DiabetesCategory: E10 | Type 2 DiabetesCategory: E11 | |
No complications | E10.9 - Type 1 diabetes mellitus without complications | E11.9 - Type 2 diabetes mellitus without complications |
Hypoglycemia without coma | E10.649 - Type 1 diabetes mellitus with hypoglycemia without coma | E11.649 - Type 2 diabetes mellitus with hypoglycemia without coma |
Hyperglycemia (uncontrolled)1 | E10.65 - Type 1 diabetes mellitus with hyperglycemia | E11.65 - Type 2 diabetes mellitus with hyperglycemia |
With kidney complication (example)2 | E10.22 - Type 1 diabetes mellitus with diabetic chronic kidney disease | E11.22 - Type 2 diabetes mellitus with diabetic chronic kidney disease |
With ophthalmic complication (example)2 | E10.331 - Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema | E11.331 - Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema |
With neurological complication (example)2 | E10.42 - Type 1 diabetes mellitus with diabetic polyneuropathy | E11.42 - Type 2 diabetes mellitus with diabetic polyneuropathy |
With circulatory complication (example)2 | E10.51 - Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene | E11.51 - Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene |
Other specified complication | E10.69 - Type 1 diabetes mellitus with other specified complication | E11.69 -Type 2 diabetes mellitus with other specified complication |
Unspecified | E10.8 - Type 1 diabetes mellitus with unspecified complications | E11.8 - Type 2 diabetes mellitus with unspecified complications |
2 The codes shown are examples of specific types of complications within that subcategory. Other codes are available for different complications within the same subcategory. Illustrative purposes only. Table is not an exhaustive or all inclusive list of ICD-10-CM diabetes diagnosis codes. Other code categories related to diabetes include E08, E09, E13, E73, P70, O24, and Z79
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 |
Artificial Pancreas Device System | S1034 | Artificial Pancreas Device System (eg, Low Glucose Suspend [LGS] Feature) Including Continuous Glucose Monitor, Blood Glucose Device, Insulin Pump And Computer Algorithm That Communicates With All Of The Devices |
Artificial Pancreas Device System (Sensor) | S1035 | Sensor; Invasive (eg, Subcutaneous), Disposable, For Use With Artificial Pancreas Device System |
Artificial Pancreas Device System (Transmitter) | S1036 | Transmitter; External, For Use With Artificial Pancreas Device System |
Artificial Pancreas Device System (Receiver) | S1037 | Receiver (Monitor); External, For Use With Artificial Pancreas Device System |
- 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: $21-$147 Medicare RVU: 0.61-4.10 99354, 99355: Medicare: $132, $100 Medicare RVU: 3.69, 2.79 |
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 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.
Coding & Reimbursement
Professional CGM
Service | Code and Description | Providers Who Can Perform the Service | Payment Level1 |
---|---|---|---|
Patient-owned CGM training and placement | 95249 Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; patient-provided equipment, sensor placement, hook-up, calibration of monitor, patient training, and printout of recording | Qualified health care providers, consistent with state scope of practice laws |
Medicare: $56 Medicare RVUs: 1.56 |
Professional CGM training, placement 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: $156 Medicare RVUs: 4.35 |
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: $36 Medicare RVUs: 1.02 |
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 |
99211-99215: Medicare: $21- $147 Medicare RVU: 0.61-4.10 99354, 99355: Medicare: $132, $100 Medicare RVU: 3.69, 2.79 |
- 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.