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.
Insulin Pump Therapy
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 |
|---|---|---|
| Infusion sets - Medicare weekly allowable code | A4221 | Supplies for maintenance of drug infusion catheter, per week (list drug separately) |
| Infusion Sets, needle | A4230 | Infusion set for external insulin pump, nonneedle cannula type |
| Infusion Sets, non-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 dressing |
| 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 |
| Insulin* | J1815 | Injection, insulin, per 5 units |
| Insulin for insulin pump** | J1817 | J1817 Insulin for administration through DME (i.e., insulin pump) per 50 units |
* For Medicare, use J1817.
** Only for insulin purchased under the DME benefit, such as for Medicare use.
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 | Code and Description | Providers Who Can Perform the Service | Payment Level* |
|---|---|---|---|
| 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 that can be performed by a non-physician or mid-level practitioner) 99212-99215 Office or other outpatient visit 99354-99355 Prolonged service, office (must be billed with 99212-99215) | MD/DO NP/PA | 99211-99215 Medicare: $19-$125 Medicare RVU: 0.52-3.46 99354-99355 Medicare: $92-$91 Medicare RVU: 2.55-2.52 |
| 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: $23-$13 Medicare RVU: 0.64-0.36 98960-98962 Medicare: $24-$9 Medicare RVU: 0.66-0.24 Medicare does not pay for 98960-98962, but does publish RVUs for these codes |
* 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.
For questions, e-mail rs.nradvance@medtronic.com with the subject line: Billing & Coding Questions.
