Many DME stakeholders were disappointed to learn CMS did not include non-rural pricing relief in its December 2021 DME Final Rule. Buried in the text, however, diabetic suppliers find a favorable coverage expansion. Effective February 28, 2022, Medicare will reimburse for continuous glucose monitors (CGMs) integrated inside insulin pumps.
CGM Classifications
To best understand the new coverage, it helps to understand CMS’s two classifications for CGM technology:
For those that don’t work as college professors or pharmaceutical commercial writers, adjunctive means “added to something else as a supplement rather than an essential part.”
Before the recent DME Final Rule, Medicare only covered non-adjunctive (therapeutic) CGMs.
New HCPCS
Because adjunctive devices work differently than non-adjunctive devices (HCPCS K0554), CMS created two new HCPCS codes. Suppliers should use the following when billing adjunctive devices:
There is one hitch. The new HCPCS codes are not active until April 1, 2022, more than a month after the implementation of the new coverage.
Interim Billing Rules
The delayed availability of the new codes require interim billing procedures for adjunctive CGMs and supplies provided between February 28 and March 31, 2022. In the interim, suppliers should use the following miscellaneous codes and narratives:
The DME MAC instructions require the narratives for both devices and supplies to include the word “ADJUNCTIVE,” but we find more descriptive narratives improve the likelihood DME MACs will pay such claims on the first submission.
Because these adjunctive devices are built into an insulin pump, suppliers should bill adjunctive CGMs and supplies on the same claim as the pump (HCPCS E0784).
While this may not be the large-scale relief expected, the expanded coverage is good for diabetic suppliers and patients benefiting from the integrated technology.
SOURCE LINKS
https://www.govinfo.gov/content/pkg/FR-2021-12-28/pdf/2021-27763.pdf
https://cgsmedicare.com/jc/pubs/news/2022/02/cope25154.html
CGM Classifications
To best understand the new coverage, it helps to understand CMS’s two classifications for CGM technology:
- Therapeutic CGMs are devices that replace standard glucose meters and do not require separate calibration or verification. The FDA calls these non-adjunctive.
- Non-therapeutic CGMs are devices that require beneficiaries to verify the CGM results with a standard glucose meter. The FDA calls these adjunctive.
For those that don’t work as college professors or pharmaceutical commercial writers, adjunctive means “added to something else as a supplement rather than an essential part.”
Before the recent DME Final Rule, Medicare only covered non-adjunctive (therapeutic) CGMs.
New HCPCS
Because adjunctive devices work differently than non-adjunctive devices (HCPCS K0554), CMS created two new HCPCS codes. Suppliers should use the following when billing adjunctive devices:
- E2102 for the CGM receiver, and
- A4238 for the monthly supplies.
There is one hitch. The new HCPCS codes are not active until April 1, 2022, more than a month after the implementation of the new coverage.
Interim Billing Rules
The delayed availability of the new codes require interim billing procedures for adjunctive CGMs and supplies provided between February 28 and March 31, 2022. In the interim, suppliers should use the following miscellaneous codes and narratives:
- Devices – Use E1399 and narrative “ADJUNCTIVE INTEGRATED CGM RECEIVER HCPCS E2102.”
- Supplies – Use A9999 and narrative “ADJUNCTIVE INTEGRATED CGM SUPPLY HCPCS A4238.”
The DME MAC instructions require the narratives for both devices and supplies to include the word “ADJUNCTIVE,” but we find more descriptive narratives improve the likelihood DME MACs will pay such claims on the first submission.
Because these adjunctive devices are built into an insulin pump, suppliers should bill adjunctive CGMs and supplies on the same claim as the pump (HCPCS E0784).
While this may not be the large-scale relief expected, the expanded coverage is good for diabetic suppliers and patients benefiting from the integrated technology.
SOURCE LINKS
https://www.govinfo.gov/content/pkg/FR-2021-12-28/pdf/2021-27763.pdf
https://cgsmedicare.com/jc/pubs/news/2022/02/cope25154.html
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