Background:

Effective for dates of service on or after January 1, 2023, benefits pertaining to continuous glucose monitor (CGM) and integrated insulin pump equipment and supplies will change for Texas Medicaid.       

The Centers for Medicare and Medicaid Services (CMS) released new adjunct CGM device and supply codes through the 2022 Annual HCPCS update and new therapeutic CGM device and supply codes in the 2023 Annual HCPCS update. Coverage details have been updated to align with the new procedure codes.

Key Details:

Major changes to this medical benefit include the following:

Therapeutic CGM

Therapeutic CGM procedure codes K0554 (device) and K0553 (supplies) will be replaced by procedure codes E2103 and A4239, respectively.

Adjunctive CGM

Previous adjunctive CGM procedure codes A9276, A9277, and A9278 will become informational only, and will be replaced by procedure codes E2102 (device) and A4238 (supplies).

Procedure code E2102 must be submitted with modifier KF* when submitting a claim for a class III CGM device, as designated by the U.S. Food and Drug Administration (FDA). No modifier* is required when submitting a claim for a class II device, as designated by the FDA.

The supply allowance for an adjunctive CGM (procedure code A4238) encompasses all items necessary for the use of the device and includes, but is not limited to, CGM sensors and transmitters. Procedure code A4238 does not include a home blood glucose monitors (BGM) or related BGM testing supplies.

No devices currently on the United States market function as standalone adjunctive CGM devices, according to the CMS. Current technology for an adjunctive CGM device operates in conjunction with an insulin pump, and its supplies are covered when the client meets the coverage criteria for both a CGM and an external insulin infusion pump.

CGM Supplies

When a CGM (procedure code E2102 or E2103) is covered, the related supply allowance (procedure code A4238 or A4239) is also covered.

The supply allowance (procedure code A4238 or A4239) will be one per 30 days. Only one procedure code A4238 or A4239 may be submitted on a claim. Services that exceed this limitation will be denied.

Requests for supplies for client-owned CGM devices require the ordering provider to submit a statement attesting that the client meets one of the following conditions:

·       The client owns a CGM device, and the client’s current condition meets coverage criteria for a CGM; or

·       The client owns a CGM device and is compliant with using the CGM device to manage their diabetes

CGM Integrated External Insulin Pumps

A CGM integrated pump (an insulin pump that has CGM capability) may be considered for reimbursement when the client meets the coverage criteria for both a CGM and an external insulin pump, as listed in the Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook, subsection 2.2.12.6.1, in the Texas Medicaid Provider Procedures Manual.

When a CGM-integrated pump is covered, its supplies (procedure code A4238 or A4239) are also covered.

Adjunctive CGM-Integrated External Insulin Pump

Because procedure codes A9276, A9277, and A9278 will become informational, an insulin pump that has adjunctive CGM capability must be submitted using a combination of procedure code E0784 with modifier UD*, and new adjunctive CGM device procedure code E2102 with modifier U4*.

Therapeutic CGM-Integrated External Insulin Pump

Insulin pumps that have therapeutic CGM capability will become a new benefit and must be submitted using a combination of procedure code E0784 with modifier UD* and therapeutic CGM device procedure code E2103 with modifier U4*.

Limitations

Only one CGM-integrated pump may be reimbursed for a qualified client who has a diabetes diagnosis. The ordering provider is responsible for requesting the appropriate device and supplies according to the client’s medical need using the appropriate procedure codes.

After the client has had a CGM-integrated insulin pump covered by Texas Medicaid, either with therapeutic CGM capability or adjunctive CGM capability, claims for a standalone CGM or regular external insulin pump will be denied.

*Modifiers specific to fee-for-service claims processing

Resources:

Diabetic Equipment and Supplies Benefits to Change for Texas Medicaid January 1, 2023 | TMHP

Next steps for providers: Providers should share this communication with their staff.

Contact:

Email ProviderRelations@cfhp.com or call 210-358-6294.

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