Retired - Glucose Monitors LCD and Related Policy Article - Revised

Joint DME MAC Article

The Glucose Monitors Local Coverage Determination (LCD) and Related Policy Article has been revised, effective for claims with dates of service on or after January 12, 2017, the date of CMS Ruling 1682R on continuous glucose monitors (CGM). The LCD and related Policy Article also includes new HCPCS codes (see below) for therapeutic CGM and the related supply allowance. These two new codes have a future effective date for claims with dates of service on or after July 1, 2017.

The revision incorporates the following updates related to therapeutic continuous glucose monitors (CGM):

1. Moved the Standard Documentation Language to a separate Standard Documentation Requirements Article (A55426) as an attachment to the LCD and related Policy Article.
   • Use modifier CG if all of the coverage requirements are met.
   • Use modifier KS if the beneficiary is non-insulin treated;
   • Use modifier KX if the beneficiary is insulin treated; or,
2. Adds modifier information when billing for therapeutic CGMs (K0554) and their related supply allowance (K0553):
3. Adds information about billing the supply allowance (K0553).
4. Adds coverage, coding and documentation requirements for therapeutic CGMs (K0554) and their related supply allowance (K0553).
   • K0554 - RECEIVER (MONITOR), DEDICATED, FOR USE WITH THERAPEUTIC CONTINUOUS GLUCOSE MONITOR SYSTEM
   • K0553 - SUPPLY ALLOWANCE FOR THERAPEUTIC CONTINUOUS GLUCOSE MONITOR (CGM), INCLUDES ALL SUPPLIES AND ACCESSORIES, 1 MONTH SUPPLY = 1 UNIT OF SERVICE
5. Adds new HCPCS codes for therapeutic CGMs and the related supply allowance:

Suppliers should pay particular attention to the claim date of service and the proper HCPCS codes used to bill the therapeutic CGM receiver and supply allowance.

Dates of Service Prior to July 1, 2017:

• Supply Allowance - A9999
• Therapeutic CGM - E1399

Dates of Service On or After July 1, 2017

• Supply Allowance – K0553
• Therapeutic CGM – K0554

Suppliers should refer to the following articles for additional information on the coverage, coding and documentation requirements for CGM devices and the supply allowance:

• Coding and Coverage – Therapeutic Continuous Glucose Monitors (CGM) (March 23, 2017)
• Billing Instructions – Continuous Glucose Monitors (April 20, 2017)

For questions about correct coding, contact the Pricing, Data Analysis, and Coding (PDAC) contractor at (877) 735-1326 during the hours of 8:30 a.m. to 4:00 p.m. CT, Monday through Friday, or e-mail the PDAC by completing the DME PDAC Contact Form at https://www.dmepdac.com/