Insulin Infusion Pumps with Integrated Continuous Glucose Sensing Capabilities and Related Accessories/Supplies – Codes E0787 and A4226 - Correct Coding

Joint DME MAC Article

Effective for claims with Dates of Service (DOS) on or after September 15, 2020, the following codes are invalid for submission to Medicare:

The HCPCS codes E0787 and A4226 were added effective January 1, 2020.  The Centers for Medicare & Medicaid Services (CMS) has become aware of complexities associated with these two codes in terms of processing claims and payment. CMS sought public input on the status of these two codes as part of the June 2, 2020 HCPCS public meeting, with a proposal to make both codes invalid for Medicare claims submission. After careful review of the comments submitted and the issues surrounding use and payment for these codes, CMS has decided to make these codes invalid for Medicare claims submission.

Insulin Pump Coding
For dates of service on or after September 15, 2020, suppliers must bill the following codes  that separately describe the functions of products coded E0787:

Suppliers must bill codes E0784 and K0554 with the RR (rental) modifier when these codes are used to describe the product previously coded as E0787.

Payment for code K0554 shall only be available if the beneficiary does not already own a CGM receiver or the five-year reasonable useful lifetime has expired. In addition, any combination of paid rental claims for codes E0787 and E0784 for insulin pumps used on a continuous basis by the same beneficiary for any dates of service shall count toward the 13-month cap on rental payments for infusion pumps.  The regulation at 42 CFR 414.229(g) requires that the supplier of the insulin pump in rental month 1 to continue furnishing the pump for the remainder of the 13-month capped rental period or until medical necessity for the pump ends, whichever occurs sooner.

Insulin Pump-Related Accessories/Supplies Coding
For dates of service on or after September 15, 2020, in order to bill for supplies previously described by HCPCS code A4226, suppliers must use the following separate insulin pump and CGM supply codes:

Instructions for Previously Submitted and Pending Claims
Claims previously submitted using codes E0787 and A4226 that were denied or rejected on or after January 1, 2020 may be corrected and resubmitted using the HCPCS codes E0784RR (rental) and K0554RR (rental).

For suppliers who have provided an E0787 and A4226 to a beneficiary with DOS on or after January 1, 2020 and have not yet submitted a claim to Medicare, suppliers may submit those claims using the HCPCS codes E0784RR (rental) and K0554RR (rental) as described above.