January 1, 2012
Last Revised Date:
March 25, 2019
This policy provides guidelines for reimbursement of diabetic supply codes when the utilization of these supplies is at a frequency over the usage listed by supply code. This policy outlines the quantity of supplies necessary for those patients that are insulin dependent and those that are non-insulin dependent. This policy applies to participating and non-participating providers.
Scope: All products are included, except
- Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
- ITS Home PAR
- ITS Host Medicare Advantage
All Insured and Administrative Services Only (ASO) accounts are included.
All claims for Diabetic Supplies must be submitted with modifier –KX (the member is being treated with insulin injections) or –KS (the member is not being treated with insulin injections) as appropriate. All Diabetic Supplies may only be dispensed per the order of a physician or other licensed health care provider. All claims for Diabetic Supplies must be submitted with a diagnosis indicating diabetes.
If quantities of supplies that exceed the utilization guidelines are dispensed, there must be documentation in the physician’s records (e.g., a specific narrative statement that adequately documents the frequency at which the patient is actually testing or a copy of member’s personal testing log) or in the supplier’s records (e.g., member’s personal testing log) that the patient is actually testing at a frequency that corroborates the quantity of supplies that have been dispensed. If the patient is regularly using quantities of supplies that exceed the utilization guidelines, new documentation must be present at least every six months.
In the case where there is an appeal from a DME vendor, then the ordering physician’s script, or any other document from the physician, which validates the patient uses more supplies than outlined in this policy, and indicates the quantity needed, will be considered as appropriate documentation. This is just documentation for appeal consideration, not a guarantee of payment.
The following sources were used as guidelines in determining the frequency of the reimbursement for the supplies associated with Diabetic Supplies in this policy:
CMS Local Coverage Determination Policies:
- L11530 - NHIC, Corp.
- L11520 - Cigna Government Services
- L196 - Noridian Administrative Services
- L27231 - National Government Services, Inc.
- L33822 - NHIC, Corp.
This policy recommends the denial of claim lines containing diabetic supply codes submitted prior to the determined renewal interval. This policy will also deny those claim lines where the quantity of the supply is greater than the maximum allowed number of units.
HCPCS modifiers -KS and -KX are utilized by the policy logic to determine if a patient is insulin dependent or non-insulin dependent. The number of units for certain supply codes is based on insulin or non-insulin dependence.
The following modifiers are required on claim lines for diabetic supplies, as appropriate:
- Modifier -KX
Must be reported for members treated with insulin, when reporting glucose monitor and other diabetes related supply codes.
- Modifier -KS
Must be reported for diabetic members not treated with insulin, when reporting glucose monitor and other diabetes related supply codes.
- Modifier -EY
Indicates no physician or other licensed health care provider order for this item or service exists.
- If all four modifier positions are blank, and a diabetic supply code is reported,
The claim line will be denied as diabetic supply codes must, at a minimum, be reported with either modifier -KX or modifier KS.
- If modifier -EY is reported with a diabetic supply code,
The claim line will be denied as modifier -EY indicates that there was no physician order for the diabetic supply code reported.
- If modifier -KS is reported with an insulin dependent diabetic supply code,
The current claim line will be denied. Note: There are exceptions where certain diabetic supplies can be reported with modifier -KS.
The policy logic will also confirm there is diabetic diagnosis code on the claim or claim line level. If no diabetic diagnosis code is present, the claim line will be denied.
Diabetic Supplies and Frequencies:
|Procedure Code||Quantity for Insulin Dependent||Days for Insulin Dependent||Quantity for Non-Insulin Dependent||Days for Non-Insulin Dependent|
* Not available for non-insulin dependent patients.
- 6 units of A4253 per 90 days are allowed for an insulin dependent member.
- 2 units of A4253 per 90 days are allowed for a non-insulin dependent member.
ICD 10 Diagnosis Codes
E08.00, E08.01, E08.10, E08.11, E08.21, E08.22, E08.29, E08.311, E08.319, E08.321, E08.329, E08.331, E08.339, E08.341, E08.349, E08.351, E08.359, E08.36, E08.39, E08.40, E08.41, E08.42, E08.43, E08.44, E08.49, E08.5, E08.51, E08.52, E08.59, E08.610, E08.618, E08.620, E08.621, E08.622, E08.628, E08.630, E08.638, E08.641, E08.649, E08.65, E08.69, E08.8, E08.9, E09.00, E09.01, E09.10, E09.11, E09.21, E09.22, E09.29, E09.311, E09.319, E09.321, E09.329, E09.331, E09.339, E09.341, E09.349, E09.351, E09.359, E09.36, E09.39, E09.40, E09.41, E09.42, E09.43, E09.44, E09.49, E09.51, E09.52, E09.59, E09.610, E09.618, E09.620, E09.621, E09.622, E09.628, E09.630, E09.638, E09.641, E09.649, E09.65, E09.69, E09.8, E09.9, E10.10, E10.11, E10.21, E10.22, E10.29, E10.311, E10.319, E10.321, E10.329, E10.331, E10.339, E10.341, E10.349, E10.351, E10.359, E10.36, E10.39, E10.40, E10.41, E10.42, E10.43, E10.44, E10.49, E10.51, E10.52, E10.59, E10.610, E10.618, E10.620, E10.621, E10.622, E10.628, E10.630, E10.638, E10.641, E10.649, E10.65, E10.69, E10.8, E10.9, E11.00, E11.01, E11.21, E11.22, E11.29, E11.311, E11.319, E11.321, E11.329, E11.331, E11.339, E11.341, E11.349, E11.351, E11.359, E11.36, E11.39, E11.40, E11.41, E11.42, E11.43, E11.44, E11.49, E11.51, E11.52, E11.59, E11.610, E11.618, E11.620, E11.621, E11.622, E11.628, E11.630, E11.638, E11.641, E11.649, E11.65, E11.69, E11.8, E11.9, E13.00, E13.01, E13.10, E13.11, E13.21, E13.22, E13.29, E13.311, E13.319, E13.321, E13.329, E13.331, E13.339, E13.341, E13.349, E13.351, E13.359, E13.36, E13.39, E13.40, E13.41, E13.42, E13.43, E13.44, E13.49, E13.51, E13.52, E13.59, E13.610, E13.618, E13.620, E13.621, E13.622, E13.628, E13.630, E13.638, E13.641, E13.649, E13.65, E13.69, E13.8, E13.9, O24.011, O24.012, O24.013, O24.019, O24.02, O24.03, O24.111, O24.112, O24.113, O24.119, O24.12, O24.13, O24.311, O24.312, O24.313, O24.319, O24.32, O24.33, O24.811, O24.812, O24.813, O24.819, O24.82, O24.83, O24.911, O24.912, O24.913, O24.919, O24.92, O24.93
Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:
- Group or Individual benefit
- Provider Participation Agreement
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
- Mandated or legislative required criteria will always supersede.
2011: Policy Approved
10/12/2015: Revised ‘Policy’ section to include submission of physician script for appeal, added ICD-10 codes; Updated EOP/EOB messaging; Added CMS LCD L33822
3/25/2019: Added procedure codes K0553 and K0554
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