CODING AND REIMBURSEMENT DIABETES

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ICD-10 CODES

Diagnosis codes are used by both healthcare professionals and hospitals to document the indication for the procedure or service performed.

The list below includes common ICD-10-CM diagnosis codes for diabetes mellitus.1

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 hyperglycemia3  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 complication4 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 mellitus5
Medication status6 Z79.4, Long term (current) use of insulin Z79.84, Long term (current) use of oral hypoglycemic drugs

HCPCS II CODES

HCPCS II codes are a supplement to CPT® codes.7 Although some HCPCS II codes are for procedures and services not classified in CPT, the majority of HCPCS II codes are for supplies, durable medical equipment (DME), drugs, and medical devices. In many situations, CPT and HCPCS II codes must be used together to completely describe a service. In particular, CPT codes indicate the procedure performed and HCPCS II codes identify the specific device, supply, DME, or drug utilized in the procedure. The HCPCS 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 continuous glucose monitoring (CGM), this is typically a DME supplier.

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, 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 CODES

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.

Code Code Description Providers Who Can Perform the Service

CY 2020 RVUs

(non-facility)8

CY 2020 Natl Avg Amount

(non-facility)9

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

     
1.58 $57

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  0.44 $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 0.77 $28
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 0.37 $13
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 0.27 $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

     
1.06 $38

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 0.92 $33
97804  Medical nutrition therapy; group (two or more individual(s), each 30 minutes 0.48 $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 0.92 $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 0.48 $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 $77 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. 3.03 $109
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 4.63 $167
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. 5.85 $211
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. 0.65 $23
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 1.28 $46
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. 2.11 $76
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. 3.06 $110
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. 4.11 $148
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.

CGM SERVICES CODES

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.

Code Code Description Providers Who Can Perform the Service

CY 2020 RVUs

(non-facility)8

CY 2020 Natl Avg 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.  1.54 $56
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.  4.23 $153
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 $37

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) 1.28 $46

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. 2.11 $76
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. 3.06 $110
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. 4.11 $148

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FREQUENTLY ASKED QUESTIONS

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Are physicians able to bill for training on Personal CGM devices?

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.

Are there specific CPT codes for insulin pump starts?

Is there a CPT code for reviewing CareLink™ software data?

Is there a CPT code for reviewing and interpreting pump data?

What are some steps to take if denied for 95250 or 95251?

Are specific ICD-10-CM diagnosis codes required to get paid for CGM?

Can a home health agency bill for CGM?

Is CGM reimbursed in an assisted living or skilled nursing facility?

How are Medicare non-facility and facility fee schedules different?

How often can CPT codes 95249, 95250, and 95251 be billed for a patient?

Can a pharmacy bill for CPT codes 95250 and 95251?

How to bill if sensor lasted <72 hrs or patient didn’t return for download?

Should 95250 be billed when a sensor is inserted or removed and data is downloaded??

What date should be used to bill 95251?

Does code 95251 require a face-to-face visit?

What is a patient’s out-of-pocket expense for professional CGM services?

Is a physician and/or hospital paid for CGM performed during an inpatient stay?

Can a cardiologist perform and bill for CGM?

Which healthcare providers can perform and bill CPT codes 95249 and 95250?

Which healthcare providers can perform and bill CPT code 95251?

Can an E/M code be billed on same day as 95249, 95250, or 95251?

Is there a reference for Medicare fees for a specific locality?

Does Medicare cover professional CGM?

Who covers CGM and have they listed CPT codes in their coverage policies?

1

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).

2

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.

3

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).

4

A seventh digit must be appended to the code to identify which eye is affected.

5

Medication status is only coded in a secondary position, following the code for diabetes mellitus.

6

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.

7

CPT copyright 2019 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.

8

Centers for Medicare & Medicaid Services. Medicare Program; CY2020 Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B Policies Final Rule; 84 Fed. Reg. 62568-63563. https://www.govinfo.gov/content/pkg/FR-2019-11-15/pdf/2019-24086.pdf. Published November 15, 2019. The total RVU as shown here is the sum of three components: physician work RVU, practice expense RVU, and malpractice RVU.

9

Medicare national average payment is determined by multiplying the sum of the three RVUs by the conversion factor. The conversion factor for CY 2020 is $36.0896 per 84 Fed. Reg. 63152. https://www.govinfo.gov/content/pkg/FR-2019-11-15/pdf/2019-24086.pdf. Published November 15, 2019. See also the January 2020 release of the PFS Relative Value File RVU20A at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html. Released November 7, 2019. Final payment to the physician is adjusted by the Geographic Practice Cost Indices (GPCI). Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the payment amount shown.