Notification



Notification Issue Date:



Policy Attachment


Attachment to Policy # 05.00.05k


Attachment:B

Policy #:05.00.05k

Description:HCPCS Codes

Title:Equipment, Supplies, and Pharmaceuticals for the Treatment of Diabetes


Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.


Healthcare Common Procedure Coding System (HCPCS) Codes that Represent Equipment, Supplies, and Pharmaceuticals for the Treatment of Diabetes

Equipment, supplies, and pharmaceuticals for the treatment of diabetes must be reported with the diagnosis code corresponding to the individual's diabetic condition in order for the item(s) to be eligible for coverage and reimbursement consideration as a treatment for diabetes.

Refer to Attachment A for a list of diagnosis codes representing diabetes.

TABLE I
THE FOLLOWING CODES REPRESENT EQUIPMENT AND SUPPLIES FOR THE TREATMENT:

CODE
NARRATIVE
A4206
Syringe with needle, sterile, 1 cc or less, each
A4207
Syringe with needle, sterile 2 cc, each
A4208
Syringe with needle, sterile 3 cc, each
A4210
Needle-free injection device, each
A4211
Supplies for self-administered injections
A4215
Needle, sterile, any size, each
A4222
Infusion supplies for external drug infusion pump, per cassette or bag (list drug separately)
A4224
Supplies for maintenance of insulin infusion catheter, per week
A4225
Supplies for external insulin infusion pump, syringe type cartridge, sterile, each
A4230
Infusion set for external insulin pump, non-needle cannula type
A4231
Infusion set for external insulin pump, needle type
A4232
Syringe with needle for external insulin pump, sterile, 3cc
A4233
Replacement battery, alkaline (other than J cell), for use with medically necessary home blood glucose monitor owned by patient, each
A4234
Replacement battery, alkaline J cell, for use with medically necessary home blood glucose monitor owned by patient, each
A4235
Replacement battery, lithium, for use with medically necessary home blood glucose monitor owned by patient, each
A4236
Replacement battery, silver oxide, for use with medically necessary home blood glucose monitor owned by patient, each
A4244
Alcohol or peroxide, per pint
A4245
Alcohol wipes, per box
A4246
Betadine or PhisoHex solution, per pint
A4247
Betadine or iodine swabs/wipes, per box
A4250
Urine test or reagent strips or tablets (100 tablets or strips)
A4253
Blood glucose test or reagent strips for home blood glucose, monitor, per 50 strips
A4255
Platforms for home blood glucose monitor, 50 per box
A4256
Normal, low, and high calibrator solution/chips
A4257
Replacement lens shield cartridge for use with laser skin piercing device, each
A4258
Spring-powered device for lancet, each
A4259
Lancets, per box of 100
A4456
Adhesive remover wipes, any type, each
A4602
Replacement battery for external infusion pump owned by patient, lithium, 1.5 volt, each
A5120
Skin barrier, wipes or swabs, each
A6257
Transparent film, sterile, 16 sq. in. or less, each dressing
A6258
Transparent film, sterile, more than 16 sq. in. but less than or equal to 48 sq. in., each dressing
A9274
External ambulatory insulin delivery system, disposable, each, includes all supplies and accessories
A9275
Home glucose disposable monitor, includes test strips
A9276
Sensor; invasive (e.g. subcutaneous), disposable, for use with interstitial continuous glucose monitoring system, one unit = 1 day supply
A9277
Transmitter; external, for use with interstitial continuous glucose monitoring system
A9278
Receiver (monitor); external, for use with interstitial continuous glucose monitoring system
E0607
Home blood glucose monitor
E0620
Skin piercing device for collection of capillary blood, laser, each
E0784
External ambulatory infusion pump, insulin
E2100
Blood glucose monitor with integrated voice synthesizer
E2101
Blood glucose monitor with integrated lancing/blood sample
K0601
Replacement battery for external infusion pump owned by patient, silver oxide, 1.5 volt, each
K0602
Replacement battery for external infusion pump owned by patient, silver oxide, 3 volt, each
K0603
Replacement battery for external infusion pump owned by patient, alkaline, 1.5 volt, each
K0604
Replacement battery for external infusion pump owned by patient, lithium, 3.6 volt, each
K0605
Replacement battery for external infusion pump owned by patient, lithium, 4.5 volt, each
S1030
Continuous noninvasive glucose monitoring device, purchase (for physician interpretation of data, use CPT code)
S1031
Continuous noninvasive glucose monitoring device, rental, including sensor, sensor replacement, and download to monitor (for physician interpretation of data, use CPT code)
S5560
Insulin delivery device, reusable pen; 1.5 ml size
S5561
Insulin delivery device, reusable pen; 3 ml size
S5565
Insulin cartridge for use in insulin delivery device other than pump; 150 units
S5566
Insulin cartridge for use in insulin delivery device other than pump; 300 units
S5570
Insulin delivery device, disposable pen (including insulin); 1.5 ml size
S5571
Insulin delivery device, disposable pen (including insulin); 3 ml size
S8490
Insulin syringes (100 syringes any size)

TABLE II
THE FOLLOWING CODES REPRESENT PHARMACEUTICALS FOR THE TREATMENT OF DIABETES:
CODE
NARRATIVE
J1610
THE FOLLOWING CODE IS USED TO REPRESENT GLUCAGEN HYPOKIT
Injection, glucagon HCl, per 1 mg
J1815
Injection, insulin, per 5 units
J1817
Insulin for administration through DME (i.e., insulin pump) per 50 units
S5550
Insulin, rapid onset, 5 units
S5551
Insulin, most rapid onset, (Lispro or Aspart); 5 units
S5552
Insulin, intermediate acting (NPH or LENTE); 5 units
S5553
Insulin, long acting; 5 units


Version Effective Date: 10/01/2017
Version Issued Date: 09/29/2017
Version Reissued Date: 04/25/2018

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