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For more information, contact the Medtronic Diabetes Reimbursement Team rs.diabetesHCPreimbursement@medtronic.com
Conditions | ICD-10-CM Diagnosis Codes: Diabetes Mellitus1 | |
---|---|---|
Type 1 Diabetes : Category E10 | Type 2 Diabetes : Category E11 | |
Diabetes mellitus without complications | ||
with no complications | E10.9, Type 1 diabetes mellitus without complications | E11.9, Type 2 diabetes mellitus without complications |
Diabetes mellitus with example complications2 | ||
uncontrolled with hyperglycemia2 | E10.65, Type 1 diabetes mellitus with hyperglycemia | E11.65, Type 2 diabetes mellitus with hyperglycemia |
with hypoglycemia without coma | E10.649, Type 1 diabetes mellitus with hypoglycemia without coma | E11.649, Type 2 diabetes mellitus with hypoglycemia without coma |
with kidney complication | E10.22, Type 1 diabetes mellitus with diabetic chronic kidney disease | E11.22, Type 2 diabetes mellitus with diabetic chronic kidney disease |
with ophthalmic complication3 | 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 | E10.42, Type 1 diabetes mellitus with diabetic polyneuropathy | E11.42, Type 2 diabetes mellitus with diabetic polyneuropathy |
with circulatory complication | E10.51, Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene | E11.51, Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene |
with foot ulcer | E10.621, Type 1 diabetes mellitus with foot ulcer | E11.621, Type 2 diabetes mellitus with foot ulcer |
with other specified complication | E10.69, Type 1 diabetes mellitus with other specified complication | E11.69, Type 2 diabetes mellitus with other specified complication |
Adjunctive codes with diabetes mellitus4 | ||
Medication status5 | Z79.4, Long term (current) use of insulin | Z79.84, Long term (current) use of oral hypoglycemic drugs |
HCPCS II codes are a supplement to CPT® codes.6
Some items have more than one code. For example, a device may have an E-code as well as an S-code. This reflects payer preference, as only private payers use S-codes although private payers may also use E-codes. A supply may have more than one A-code, which also reflects payer preference in that one A-code is not payable by certain payers but another A-code is.
Product | Code | Description |
---|---|---|
NON-MEDICARE | ||
Insulin Pump | E0784 | External ambulatory infusion pump, insulin |
S1034 | Artificial pancreas device system (e.g., low glucose suspend (LGS) feature) including continuous glucose monitor, blood glucose device, insulin pump, and computer algorithm that communicates with all of the devices | |
Infusion sets | A4224 | Supplies for maintenance of insulin infusion catheter, per week |
Infusion sets, non-needle | A4230 | Infusion set for external insulin pump, non-needle cannula type (each) |
Infusion sets, needle | A4231 | Infusion set for external insulin pump, needle type (each) |
Pump reservoirs | A4232 | Syringe with needle for external insulin pump, sterile, 3 cc |
Remote monitor | A9279 | Monitoring feature/device, stand-alone or integrated, any type, includes all accessories, components and electronics, not otherwise classified |
CGM transmitter | A9277 | Transmitter; external, for use with interstitial continuous glucose monitoring system |
S1036 | Transmitter; external, for use with artificial pancreas device system | |
CGM sensors | A9276 | Sensor; invasive (e.g., subcutaneous), disposable, for use with interstitial continuous glucose monitoring system, one unit = 1 day supply |
S1035 | Sensor; invasive (e.g., subcutaneous), disposable, for use with artificial pancreas device system | |
CGM receiver | A9278 | Receiver (monitor); external, for use with interstitial continuous glucose monitoring system |
S1037 | Receiver (monitor); external, for use with artificial pancreas device system | |
Alcohol wipes | A4245 | Alcohol wipes, per box |
Betadine swabs, per box | A4247 | Betadine or iodine swabs/wipes, per box |
Test strips | A4253 | Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips |
Lancets | A4259 | Lancets, per box of 100 |
Adhesive, liquid, per ounce | A4364 | Adhesive, liquid or equal, any type, per oz |
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 |
Home glucose monitor | E0607 | Home blood glucose monitor |
Replacement battery, pump, silver oxide (MMT-104) | K0601 | Replacement battery for external infusion pump owned by patient, silver oxide, 1.5 volt, each |
MEDICARE | ||
Insulin pump (13 month rental) | E0784 | External ambulatory infusion pump, insulin |
Infusion sets | A4224 | Supplies for maintenance of insulin infusion catheter, per week |
Pump reservoirs | A4225 | Supplies for external insulin infusion pump, syringe type cartridge, sterile, each |
Alcohol wipes | A4245 | Alcohol wipes, per box |
Betadine swabs, per box | A4247 | Betadine or iodine swabs/wipes, per box |
Test strips | A4253 | Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips |
Lancets | A4259 | Lancets, per box of 100 |
Adhesive, liquid, per ounce | A4364 | Adhesive, liquid or equal, any type, per oz |
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 |
Home glucose monitor | E0607 | Home blood glucose monitor |
Replacement battery, pump, silver oxide (MMT-104) | K0601 | Replacement battery for external infusion pump owned by patient, silver oxide, 1.5 volt, each |
INSULIN | ||
Insulin | J1815 | Injection, insulin, per 5 units |
Insulin for insulin pumps | J1817 | Insulin for administration through DME (i.e., insulin pump) per 50 units |
Diabetes education may consist of patient management to begin insulin pump therapy (also called continuous subcutaneous insulin infusion or CSII) as it relates to insulin, such as carb ratios, basal rates, sick day management, or insulin sensitivity for correction factor. Medical nutrition therapy specifically focuses on dietary intervention to ensure eating habits are appropriate for persons with diabetes. For Medicare, diabetes self-management training and medical nutrition therapy are completely separate benefits.
Providers use CPT® codes for all services, along with select HCPCS II codes. 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 payers use Medicare RVUs as the basis of their payment rates. The RVUs shown are for services performed in the non-facility setting, e.g., in the office.
CPT® Code | Code Description | Providers Who Can Perform the Service | CY 2022 Total RVUs (non-facility)7 |
CY 2022 Medicare National Unadjusted Amount (non-facility)8 |
Notes |
---|---|---|---|---|---|
Diabetes Education by Staff or Other Non-Physician | |||||
G0108 | Diabetes outpatient self-management training services, individual, per 30 minutes | Office Nurse (RN) in ADA-recognized program
Certified Diabetes Educator (CDE) in ADA-recognized program
Registered Dietician (RD) in ADA-recognized program |
1.62 | $56 | HCPCS codes G0108-G0109 are required for Medicare
CPT codes 98960-98962 and HCPCS S-codes are used by private payers. Medicare does not recognize 98960- 98962, but does publish reference RVUs and payment amounts for these codes. |
G0109 | Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes | 0.46 | $16 | ||
98960 | Education and training for patient self-management by a qualified, non-physician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient | 0.85 | $29 | ||
98961 | Education and training for patient self-management by a qualified, non-physician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; 2-4 patients | 0.40 | $14 | ||
98962 | Education and training for patient self-management by a qualified, non-physician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; 5-8 patients | 0.30 | $10 | ||
S9445 | Patient education, not otherwise classified, non-physician provider, individual, per session | - | - | ||
S9446 | Patient education, not otherwise classified, non-physician provider, group, per session | - | - | ||
Diabetes Medical Nutrition Therapy | |||||
97802 | Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes | Registered Dietician (RD)
Certified or Licensed Nutritionist |
1.08 | $37 | For Medicare, the benefit is limited to 3 hours of one-to-one service the first year and two hours each subsequent year.
Diabetes self-management training and medical nutrition therapy cannot be reported on the same date for the same patient.
HCPCS S-code A9452 is used by private payers only. |
97803 | Medical nutrition therapy; reassessment and intervention, individual, face-to-face with the patient, each 15 minutes | 0.94 | $33 | ||
97804 | Medical nutrition therapy; group (two or more individual(s), each 30 minutes | 0.50 | $17 | ||
G0270 | Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease), individual, face-to-face with the patient, each 15 minutes | 0.94 | $33 | ||
G0271 | Medical nutrition therapy, reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition, or treatment regimen (including additional hours needed for renal disease), group (2 or more individuals), each 30 minutes | 0.50 | $17 | ||
S9452 | Nutrition classes, non-physician provider, per session | - | - | ||
Diabetes Education by Physician or Equivalent Practitioner | |||||
99202 | Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter. | Physician (MD, DO)
Physician Assistant (PA)
Nurse Practitioner (NP)
Clinical Nurse Specialist (CNS) |
2.14 | $74 | Physicians and equivalents report E/M codes for education services that they personally perform. |
99203 | Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 30-44 minutes of total time is spent on the date of the encounter. | 3.29 | $114 | ||
99204 | Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter | 4.90 | $170 | ||
99205 | Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 60-74 minutes of total time is spent on the date of the encounter. | 6.48 | $224 | ||
99211 | Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal. | 0.68 | $24 | ||
99212 | Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter | 1.66 | $57 | ||
99213 | Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter. | 2.66 | $92 | ||
99214 | Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter. | 3.75 | $130 | ||
99215 | Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter. | 5.29 | $183 | ||
Other Physician Services | |||||
G0454 | Physician documentation of face-to-face visit for durable medical equipment determination performed by nurse practitioner, physician assistant or clinical nurse specialist | Physician (MD, DO) | 0.26 | $9 | When DME, such as an insulin pump, is ordered by an NP or PA, the physician must countersign that the NP or PA had a face-to-face encounter with the patient prior to writing the order.
When the physician personally performs the face-to-face encounter, the physician uses an E/M code. |
Codes related to continuous glucose monitoring (CGM) differentiate between the technical service of sensor placement and patient training, performed by office staff, and the professional service of interpreting the CGM data, performed by clinicians. For the technical service, different codes are assigned depending on whether the patient or the physician practice owns the CGM equipment.
Providers use CPT codes for all services, along with select HCPCS II codes. 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 payers use Medicare RVUs as the basis of their payment rates. The RVUs shown are for services performed in the non-facility setting, e.g., in the office.
CPT® Code | Code Description | Providers Who Can Perform the Service | CY 2022 Total RVUs (non-facility)8 |
CY 2022 Medicare National Unadjusted Amount (non-facility)9 |
Notes |
---|---|---|---|---|---|
CGM Sensor Placement and Patient Training: Patient-owned ("Personal" or "Real-Time" CGM) | Codes 95249 and 95250 are the technical service codes. | ||||
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 | Office staff, eg, RN or CDE, "incident to" the physician service. | 1.73 | $60 | |
CGM Sensor Placement and Patient Training: Physician-owned ("Professional" or "Retrospective" CGM) | |||||
95250 | Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; physician or other qualified health care professional (office) provided equipment, sensor placement, hook-up, calibration of monitor, patient training, removal of sensor, and printout of recording | Office staff, eg, RN or CDE, "incident to" the physician service. | 4.38 | $152 | |
Interpretation of CGM Data | |||||
95251 | Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; analysis, interpretation and report | Physician (MD, DO) Physician Assistant (PA) Nurse Practitioner (NP) Clinical Nurse Specialist (CNS) |
1.02 | $35 | Code 95251 is the professional service code.
The data analysis and interpretation need not be performed face-to-face with the patient. |
Office Visit | |||||
99212 | Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter | Physician (MD, DO)Physician Assistant (PA) Nurse Practitioner (NP)Clinical Nurse Specialist (CNS) | 1.66 | $57 | An office visit E/M code can only be billed separately on the same date as 95249, 99250, 95251 if a medically necessary, separately identifiable evaluation and management service takes place in addition to the CGM service. Modifier -25 is appended to the E/M to indicate this.
E/M codes may be used for pre-CGM and post-CGM office visits. |
99213 | Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter. | 2.66 | $92 | ||
99214 | Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter. | 3.75 | $130 | ||
99215 | Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter. | 5.29 | $183 | ||
+99417 | Prolonged office or other outpatient evaluation and management service(s) beyond the minimum required time of the primary procedure which has been selected using total time, requiring total time with or without direct patient contact beyond the usual services, on the date of the primary services, each 15 minutes of total time. (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services) | 0.66 | $23 | These are add-on codes that must be billed with an appropriate base code. | |
+G2212 | Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact. (List separately in addition to CPT codes 99205, 99215 for office or other outpatient evaluation and management services) | 0.96 | $33 |
Product | Specification | NDC |
---|---|---|
InPen™ Humalog® | Blue | 62088-0000-31 |
Grey | 62088-0000-32 | |
Pink | 62088-0000-33 | |
InPen™ Novolog®/Fiasp® | Blue | 62088-0000-34 |
Grey | 62088-0000-35 | |
Pink | 62088-0000-36 | |
Notes: If prescribing InPen through an Electronic Medical Record (EMR), please note that the product is available in three (3) different colors and two (2) different models specific to the type of insulin being prescribed. Additionally, note that patients will need a separate prescription for the insulin cartridges associated with their use of InPen. See NDCs for compatible insulin cartridges below.
If you are not prescribing InPen through an EMR, complete this online order form and email it to rx@companionmedical.com or fax to 877-444-2373. |
||
i-Port Advance™ Injection Port |
6MM Cannula | 76300-0100-10 |
9MM Cannula | 76300-0101-10 |
Patients will need a separate prescription for insulin cartridges with their use of the InPenTMsmart insulin pen.
Product | Specification | NDC |
---|---|---|
Humalog® | U100 3ml Cartridge | 00002-7516-59 |
Novolog® | U100 3ml Cartridge | 00169-3303-12 |
Fiasp® | U100 3ml Cartridge | 00169-3205-15 |
Yes. CPT code 95249 is the code for CGM technical services, including patient training, for Personal or Real-Time CGM where the patient owns the CGM equipment.
Other code categories are available for less common types of diabetes mellitus including: E08, Diabetes mellitus due to underlying condition; E09, Drug or chemical induced diabetes mellitus; E13, Other specified diabetes mellitus; and O24, Diabetes mellitus in pregnancy, childbirth, and the puerperium (pre-existing and gestational).
The codes shown are examples of specific types of complications within that subcategory. Other codes are available for different complications within the same subcategory. The table is for illustrative purposes only and is not an exhaustive or all-inclusive list of ICD-10-CM diabetes diagnosis codes.
Diabetes characterized as uncontrolled, out-of-control, inadequately controlled, or poorly controlled diabetes is coded to hyperglycemia in ICD-10-CM, unless the lack of control refers to low blood sugar (hypoglycemia).
A seventh digit must be appended to the code to identify which eye is affected.
Medication status is only coded in a secondary position, following the code for diabetes mellitus.
Code Z79.4 can also be assigned to a patient with type 2 diabetes mellitus who routinely uses insulin for control. If a patient is treated with both oral hypoglycemic agents and insulin, only Z79.4 is assigned.
CPT copyright 2021 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
Centers for Medicare & Medicaid Services. Medicare Program; Revisions to Payment Policies under the Medicare Physician Fee Schedule, Quality Payment Program and Other Revisions to Part B for CY 2022; https://www.cms.gov/medicaremedicare-fee-service-paymentphysicianfeeschedpfs-federal-regulation-notices/cms-1751-f. Published November 19, 2021 with file updates published December 20, 2021. The total RVU as shown here is the sum of three components: physician work RVU, practice expense RVU, and malpractice RVU.
Medicare national average payment is determined by multiplying the sum of the three RVUs by the conversion factor. The conversion factor for CY 2022 is $34.6062.
All Medicare rates displayed in this table reflect the “national unadjusted” amounts inclusive of beneficiary cost-sharing and do not reflect any additional payment adjustments, such as the 2% sequester reduction mandated by the Budget Control Act of 2011 or the 4% PAYGO reduction triggered by the American Rescue Plan in December 2020. Please note that on December 10, 2021, legislation was enacted to delay the 2% sequestration for 3 months (January 1–March 31, 2022), followed by a reduction of 1% for 3 months (April 1–June 30, 2022). The full 2% sequestration cut will go back into effect on July 1, 2022. The 4% PAYGO reduction was postponed through January 1, 2023.
Humalog® is a registered trademark of Eli Lilly and Company. Fiasp® and Novolog® are registered trademarks of Novo Nordisk A/S.