Continuous Glucose Monitors (CGMs) -- New Codes

Continuous Glucose Monitors (CGMs)

On December 28, 2021, we published the Medicare DMEPOS final rule in the Federal Register. This addressed the classification and payment of adjunctive CGMs under the Medicare Part B benefit for DME.

This rule expanded the classification of DME to a larger group of non-implantable CGMs, regardless of whether the CGMs are non-adjunctive (can alert patients when glucose levels are approaching dangerous levels, including while they sleep and also replace blood glucose monitors) or adjunctive (can alert patients when glucose levels may be approaching dangerous levels, including while they sleep but don’t replace blood glucose monitors), as long as the CGMs otherwise satisfy the regulatory definition of DME (durable equipment used in the home).

We aren’t aware at this time of an adjunctive CGM stand-alone receiver, transmitter, and sensor system that meets the DME definition. However, adjunctive CGM supplies and accessories used in conjunction with an insulin pump that also does the functions of an adjunctive CGM could be classified and covered under the DME benefit in cases where the patient meets the Medicare coverage and medical necessity requirements for both an insulin pump and an adjunctive CGM.

Although the final rule classifies adjunctive CGMs as DME items, Section 1862(a)(1)(A) of the Act still prohibits Medicare payment for these items if they aren’t determined reasonable and necessary for the treatment of the diabetes illness. Until a local or national coverage determination is established for these items, MACs will make coverage decisions regarding these items on a claim-by-claim basis.

Adjunctive CGM Supplies and Accessories for Each Month of Use

For dates of service February 28, 2022 - March 31, 2022, suppliers billing for adjunctive CGM supplies and accessories used in conjunction with an insulin pump that also do the functions of an adjunctive CGM should use:

• HCPCS code A9999 (Miscellaneous DME Supply or Accessory, Not Otherwise Specified) to bill for adjunctive CGM supplies and accessories provided for each month of use

Effective April 1, 2022, HCPCS codes A9276 and A9277 are invalid for Medicare use for billing individual CGM supplies and accessories and not reflective of a monthly allowance. Effective April 1, 2022, we added HCPCS code A4238 (Supply allowance for adjunctive continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service) to the HCPCS file to describe a month’s supply of adjunctive CGM supplies and accessories.

Adjunctive CGM or Receiver for Each Month of Use

For dates of service February 28, 2022 - March 31, 2022, suppliers should use HCPCS code E1399 (Durable medical equipment, miscellaneous) to describe a CGM for this purpose until code E2102 is effective.

Effective April 1, 2022, HCPCS code A9278 is invalid for Medicare use for billing adjunctive CGM receivers.

Effective April 1, 2022, we added HCPCS code E2102 (Adjunctive Continuous Glucose Monitor or Receiver) to the HCPCS file to describe the use of an insulin pump with an integrated adjunctive CGM receiver function.

For dates of service on or after April 1, 2022, suppliers should bill using HCPCS modifier for a rental (RR) both codes E0784 (External Ambulatory Infusion Pump, Insulin) and E2102 to describe the rental of an insulin pump with integrated adjunctive CGM receiver functionality.

Pricing for Continuous Glucose Monitors (CGMs)

Pricing for 1 month of adjunctive CGM supplies and accessories submitted under the HCPCS codes below, with payment based on local fee schedule amounts established by DME MACs.

• A9999, effective for dates of service February 28, 2022 - March 31, 2022, or
• A4238, effective for dates of service beginning April 1, 2022

Pricing for an adjunctive CGM monitor is based on local fee schedule amounts set by DME MACs as follows:

• Submitted under HCPCS code E2102, effective for dates of service beginning April 1, 2022, or
• Submitted under HCPCS code E1399 (dates of service February 28 - March 31, 2022)

Payment for E2102 (or E1399 for dates of service between February 28, 2022 - March 31, 2022), is only available for the CGM receiver function of a rented insulin infusion pump if the patient doesn’t already own a CGM receiver of any kind (either adjunctive or non-adjunctive) that is less than 5 years old, and the patient doesn’t already own an insulin pump of any kind that is less than 5 years old.

In addition, switching from an insulin pump without the CGM receiver feature to an insulin pump with the CGM receiver feature doesn’t result in either an interruption in the period of continuous use for the insulin pump or the start of a new 13-month rental cap period for the insulin pump for the patient. The supplier will transfer title of the equipment to the patient on the first day following the end of the 13th month of use by the patient. Regulation 42 CFR 414.229(g) requires that the supplier of the insulin pump in the first month must continue to provide the pump for the remainder of the 13-month capped rental period or until medical necessity for the pump ends, whichever is earlier.