Coverage and Reimbursement
Commonly Billed Codes
Medtronic has developed this reimbursement guide to assist you in billing for your services related to the initiation and follow-up of patients who have been prescribed the MiniMed Paradigm® REAL-Time Revel System, consisting of the MiniMed Paradigm 523 or 723 Insulin Pump and REAL-Time Continuous Glucose Monitoring (CGM); the Guardian® REAL-Time System; or the iPro™ Professional CGM.
Medtronic provides this information for your convenience only. It is not intended as a recommendation regarding clinical practice. It is the responsibility of the provider to determine coverage and submit appropriate codes, modifiers, and charges for the services that were rendered. Please contact your local carrier or payor to verify coverage criteria and billing/coding guidelines.
Professional CGM
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.*
| ICD-9 | Description | Fifth Digit | |||
|---|---|---|---|---|---|
| 0 | 1 | 2 | 3 | ||
| 250.0 | Diabetes mellitus without mention of complication | type II or unspecified type, not stated as uncontrolled | type I [juvenile type], not stated as uncontrolled | type II or unspecified type, uncontrolled | type I [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 | ||||
*Excludes 250.2 and 250.3 series for diabetes with coma.
CPT/HCPCS II Codes for Provider Services
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.
Professional CGM
| Service | Description | Providers Who Can Perform the Service | Payment Level* |
|---|---|---|---|
| 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: $128 Medicare RVUs: 3.56 |
| 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: $40 Medicare RVUs: 1.10 |
| Pre-/post-CGM evaluation | Evaluation and Management (E/M) Codes:** 99212-99215 Office or other outpatient visit 99354-99355 Prolonged service, office (must be billed with 99212-99215) | MD/DO NP/PA | 99212-99215 Medicare: $37-$125 Medicare RVU: 1.03-3.46 99354-99355 Medicare: $92-$91 Medicare RVU: 2.55-2.52 |
* Medicare 2009 national average allowable amount, rounded to the nearest full dollar amount. Includes 20% patient copayment amount. All RVUs are for services performed in the physician’s office.
Source: Medicare Physician Fee Schedule 2009.
** An office visit can only be billed separately when a CGM service is provided to the same patient on the same day if a full-scale, separately identifiable evaluation and management service takes place in addition to the CGM service. In this circumstance, the modifier -25 should be billed with the E/M code to indicate that a separate and distinct E/M service was provided.
For questions, email rs.nradvance@medtronic.com with the subject line: Billing & Coding Questions
Personal CGM
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.*
| ICD-9 | Description | Fifth Digit | |||
|---|---|---|---|---|---|
| 0 | 1 | 2 | 3 | ||
| 250.0 | Diabetes mellitus without mention of complication | type II or unspecified type, not stated as uncontrolled | type I [juvenile type], not stated as uncontrolled | type II or unspecified type, uncontrolled | type I [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 | ||||
*Excludes 250.2 and 250.3 series for diabetes with coma.
HCPCS II Device Codes
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 |
|---|---|---|
| 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 dressing |
| Sensors (per diem) | A9276 | Sensor; invasive (e.g., subcutaneous), disposable, for use with interstitial continuous glucose monitoring system, 1 unit = 1 day supply |
| CGM Transmitter | A9277 | Transmitter; external, for use with interstitial continuous glucose monitoring system |
| CGM Receiver (Guardian® System only) | A9278 | Receiver (monitor); external, for use with interstitial continuous glucose monitoring system |
CPT/HCPCS II Codes for Provider Services
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 | Description | Providers Who Can Perform the Service | Payment Level* |
|---|---|---|---|
| Initial 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 RVUs: 3.56 Medicare does not cover Personal CGM, but does publish RVUs for these codes. |
| 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 RVUs: 1.10 Medicare does not cover Personal CGM, but does publish RVUs for these codes. |
| Pre-/post-CGM evaluation | Evaluation and Management (E/M) Codes:*** 99212-99215 Office or other outpatient visit 99354-99355 Prolonged service, office (must be billed with 99212-99215) | MD/DO NP/PA | 99212-99215 Medicare: $37-$125 Medicare RVU: 1.03-3.46 99354-99355 Medicare: $92-$91 Medicare RVU: 2.55-2.52 |
* Medicare 2009 national average allowable amount, rounded to the nearest full dollar amount. Includes 20% patient copayment amount. All RVUs are for services performed in the physician’s office.
Source: Medicare Physician Fee Schedule 2009.
** Use the reduced service modifier (-52) if the patient owns the equipment (therefore not an expense to the provider).
*** An office visit can only be billed separately when a CGM service is provided to the same patient on the same day if a full-scale, separately identifiable evaluation and management service takes place in addition to the CGM service. In this circumstance, the modifier -25 should be billed with the E/M code to indicate that a separate and distinct E/M service was provided.
For questions, e-mail rs.nradvance@medtronic.com with the subject line: Billing & Coding Questions.
