Chapter. CPT only copyright 2008 American Medical Association. All rights reserved. 15Diabetic Equipment and Supplies

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1 Chapter 15Diabetic Equipment and Supplies Enrollment Benefits, Limitations, and Authorization Requirements Glucose Monitor Benefits Limitations Prior Authorization Requirements Insulin Pump Benefits Limitations Prior Authorization Requirements Diabetic Supplies Benefits Limitations Documentation of Receipt Claims Information Reimbursement TMHP-CSHCN Services Program Contact Center CPT only copyright 2008 American Medical Association. All rights reserved.

2 Chapter Enrollment To enroll in the CSHCN Services Program, providers of diabetic equipment and supplies must be actively enrolled in Texas Medicaid, have a valid Provider Agreement with the CSHCN Services Program, have completed the CSHCN Services Program enrollment process, and comply with all applicable state laws and requirements. Out-of-state diabetic equipment and supplies providers must meet all these conditions, and be located in the United States, within 50 miles of the Texas state border, and approved by the Department of State Health Services (DSHS). Important: CSHCN Services Program providers are responsible for knowing, understanding, and complying with the laws, administrative rules, and policies of the CSHCN Services Program and Texas Medicaid. By enrolling in the CSHCN Services Program, providers are charged not only with knowledge of the adopted CSHCN Services Program agency rules published in Title 25 Texas Administrative Code (TAC), but also with knowledge of the adopted Medicaid agency rules published in 1 TAC, Part 15, and specifically including the fraud and abuse provisions contained in Chapter 371. CSHCN Services Program providers also are required to comply with all applicable laws, administrative rules, and policies that apply to their professions. Specifically, it is a violation of program rules when a provider fails to provide health-care services or items to recipients in accordance with accepted medical community standards and standards that govern occupations, as explained in 1 TAC (a)(6)(A) for Medicaid providers, which also applies to CSHCN Services Program providers as set forth in 25 TAC 38.6(b)(1). Accordingly, CSHCN Services Program providers can be subject to sanctions for failure to, at all times, deliver health-care items and services to recipients in full accordance with all applicable licensure and certification requirements. These include, without limitation, requirements related to documentation and record maintenance, such that a CSHCN Services Program provider can be subject to sanctions for failure to create and maintain all records required by his or her profession, as well as those required by the CSHCN Services Program and Texas Medicaid. Refer to: Section 2.1, Provider Enrollment, on page 2-2 for more detailed information about CSHCN Services Program provider enrollment procedures Benefits, Limitations, and Authorization Requirements Glucose Monitor Benefits Glucose monitors are a benefit of the CSHCN Services Program. The following procedure codes may be used to bill for the purchase of glucose monitors: A9275, E0607, E2100, and E2101. Glucose monitors may be authorized for clients with Type 1 and Type 2 diabetes mellitus Limitations Glucose monitors are limited as follows: Procedure Code A9275 E0607 E2100 E2101 Limitation As needed 1 per 3 years 1 per 3 years with prior authorization 1 per 3 years with prior authorization Prior authorization is not required for glucose monitor procedure codes A9275 and E0607, which are limited to the following diagnosis codes: Diagnosis Code Description Secondary diabetes mellitus without mention of complication, not stated as, or unspecified Secondary diabetes mellitus without mention of complication, 15 2 CPT only copyright 2008 American Medical Association. All rights reserved.

3 Diabetic Equipment and Supplies Diagnosis Code Description Secondary diabetes mellitus with ketoacidosis, not stated as, or unspecified Secondary diabetes mellitus with ketoacidosis, Secondary diabetes mellitus with hyperosmolarity, not stated as, or unspecified Secondary diabetes mellitus with hyperosmolarity, Secondary diabetes mellitus with other coma, not stated as, or unspecified Secondary diabetes mellitus with other coma, Secondary diabetes mellitus with renal manifestations, not stated as, or unspecified Secondary diabetes mellitus with renal manifestations, Secondary diabetes mellitus with ophthalmic manifestations, not stated as, or unspecified Secondary diabetes mellitus with ophthalmic manifestations, Secondary diabetes mellitus with neurological manifestations, not stated as, or unspecified Secondary diabetes mellitus with neurological manifestations, Secondary diabetes mellitus with peripheral circulatory disorders, not stated as, or unspecified Secondary diabetes mellitus with peripheral circulatory disorders, Secondary diabetes mellitus with other specified manifestations, not stated as, or unspecified Secondary diabetes mellitus with other specified manifestations, Secondary diabetes mellitus with unspecified complication, not stated as, or unspecified Secondary diabetes mellitus with unspecified complication, Diabetes mellitus without mention of complication, type II or unspecified type, not stated as Diabetes mellitus without mention of complication, type I [juvenile type], not stated as Diabetes mellitus without mention of complication, type II or unspecified type, Diabetes mellitus without mention of complication, type I [juvenile type], Diabetes with ketoacidosis, type II or unspecified type, not stated as Diabetes with ketoacidosis, type I [juvenile type], not stated as Diabetes with ketoacidosis, type II or unspecified type, Diabetes with ketoacidosis, type I [juvenile type], Diabetes with hyperosmolarity, type II or unspecified type, not stated as Diabetes with hyperosmolarity, type I [juvenile type], not stated as Diabetes with hyperosmolarity, type II or unspecified type, Diabetes with hyperosmolarity, type I [juvenile type], Diabetes with other coma, type II or unspecified type, not stated as Diabetes with other coma, type I [juvenile type], not stated as Diabetes with other coma, type II or unspecified type, Diabetes with other coma, type I [juvenile type], 15 CPT only copyright 2008 American Medical Association. All rights reserved. 15 3

4 Chapter 15 Diagnosis Code Description Diabetes with renal manifestations, type II or unspecified type, not stated as Diabetes with renal manifestations, type I [juvenile type], not stated as Diabetes with renal manifestations, type II or unspecified type, Diabetes with renal manifestations, type I [juvenile type], Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as Diabetes with ophthalmic manifestations, type I [juvenile type], not stated as Diabetes with ophthalmic manifestations, type II or unspecified type, Diabetes with ophthalmic manifestations, type I [juvenile type], Diabetes with neurological manifestations, type II or unspecified type, not stated as Diabetes with neurological manifestations, type I [juvenile type], not stated as Diabetes with neurological manifestations, type II or unspecified type, Diabetes with neurological manifestations, type I [juvenile type], Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as Diabetes with peripheral circulatory disorders, type I [juvenile type], not stated as Diabetes with peripheral circulatory disorders, type II or unspecified type, Diabetes with peripheral circulatory disorders, type I [juvenile type], Diabetes with other specified manifestations, type II or unspecified type, not stated as Diabetes with other specified manifestations, type I [juvenile type], not stated as Diabetes with other specified manifestations, type II or unspecified type, Diabetes with other specified manifestations, type I [juvenile type], Diabetes with unspecified complication, type II or unspecified type, not stated as Diabetes with unspecified complication, type I [juvenile type], not stated as Diabetes with unspecified complication, type II or unspecified type, Diabetes with unspecified complication, type I [juvenile type], 7751 Neonatal diabetes mellitus 15 4 CPT only copyright 2008 American Medical Association. All rights reserved.

5 Diabetic Equipment and Supplies Prior Authorization Requirements Prior authorization is required for reimbursement of blood glucose monitors with special features (procedure codes E2100 and E2101). The following documentation supporting medical necessity of the special feature requested must be submitted with the prior authorization request: Special feature Integrated voice synthesizer (procedure code E2100). Supporting documentation must include an additional diagnosis such as significant visual impairment and must include a statement from the physician that the client is unable to use a regular monitor and that the visual impairment is not correctable. Special feature Integrated lancing/blood sample (procedure code E2101). Supporting documentation must include a diagnosis of diabetes and significant manual dexterity impairment related, but not limited, to neuropathy, seizure activity, cerebral palsy or Parkinson's. The documentation must include a statement from the physician that the client is unable to use a regular monitor and has a significant manual dexterity impairment that is not correctable. Requests for authorization should be submitted on the CSHCN Services Program Prior Authorization and Authorization Request for Durable Medical Equipment (DME) form. Refer to: Section 4.3, Prior Authorizations, on page 4-4 for detailed information about prior authorization requirements Insulin Pump Benefits The purchase or rental of external insulin pumps is a benefit of the CSHCN Services Program using procedure code E0784. Rental of an external insulin pump may be reimbursed for a 3-month trial, which must occur before the purchase can be authorized. In order for an external insulin pump to be considered for purchase, the physician must provide documentation that it is the appropriate equipment for the client and that the client is compliant with use. Related supplies for an external ambulatory insulin pump may be prescribed by any physician. Reimbursement for an internal insulin pump is included in the reimbursement for the surgery to place the pump. No separate payment will be made. Note: Insulin and insulin syringes are available through the Vendor Drug Program Limitations External insulin pumps are limited as follows: Procedure Code Limitation E0784 Three month trial rental (must occur before a purchase can be authorized) E0784 Purchase 1 per 3 years with prior authorization Prior Authorization Requirements Prior authorization is required for the rental and purchase of an external ambulatory insulin pump (procedure code E0784). Prior authorization may be granted if the endocrinologist is the prescribing physician and if documentation submitted with the CSHCN Services Program Prior Authorization Request for External Insulin Pump form includes past and current blood glucose levels including the most recent glycosylated hemoglobin level (Hb/A1C), and at least one of the following: History of severe glycemic reactions History of brittle diabetes Frequent hypoglycemic/hyperglycemic reactions History of nocturnal hypoglycemia History of extreme insulin sensitivity with very low insulin requirements History of wide fluctuations in blood glucose levels before meals 15 CPT only copyright 2008 American Medical Association. All rights reserved. 15 5

6 Chapter 15 History of Dawn phenomenon with fasting blood glucose levels exceeding 200 mg/dl History of day-to-day variations in work schedule, meal schedule, or activity levels requiring multiple insulin injections Refer to: Section 4.3, Prior Authorizations, on page 4-4 for detailed information about prior authorization requirements Diabetic Supplies Benefits Providers may be reimbursed for expendable medical supplies related to the rental of an insulin pump Limitations The following diabetic supplies do not require prior authorization, but are limited to the diagnosis codes listed in Section , Glucose Monitor, on page 15-2 and should be listed individually on the claim for reimbursement consideration. If a client requires more than the amounts listed in the following table, and the claim is denied, the provider must submit documentation of medical necessity with the appeal. Procedure Code Maximum Limits Procedure Code Maximum Limits Procedure Code Maximum Limits A4230 As needed A4231 As needed A4232 As needed A4233 As needed A4234 As needed A4235 As needed A4236 As needed A4250 As needed A4252 As needed A4253 As needed A4256 As needed A per year A4259 As needed A4601* As needed A6257* As needed A6258* As needed A6259* As needed A9150* As needed** A9900* As needed*** *These procedure codes are not diagnosis restricted. **Use this procedure code for glucose tabs/gel. ***Use this procedure code for a replacement leg bag. (Initial leg bag is included in the pump purchase.) 15.3 Documentation of Receipt When the equipment is delivered, providers must complete the CSHCN Services Program Documentation of Receipt form on page B-100 or the CSHCN Services Program Documentation of Receipt (Spanish) form on page B-101. The date of delivery on the form is the date of service that should appear on the claim. The provider must request a signature from the client or client s representative at the time of delivery. The provider should retain this form and not submit it with the claim. Providers must maintain a copy of this form in their files for the life of the piece of equipment or until the equipment is authorized for replacement Claims Information Diabetic equipment and supplies must be submitted to TMHP in an approved electronic format or on the CMS-1500 claim form. Providers may purchase CMS-1500 claim forms from the vendor of their choice. TMHP does not supply the forms. When completing a CMS-1500 claim form, all required information must be included on the claim, as information is not keyed from attachments. Superbills or itemized statements are not accepted as claim supplements CPT only copyright 2008 American Medical Association. All rights reserved.

7 Diabetic Equipment and Supplies Home health DME providers must use benefit code DM3 on all claims and authorization requests. All other providers must use benefit code CSN on all claims and authorization requests. Refer to: Chapter 36, TMHP Electronic Data Interchange (EDI), on page 36-1 for information on electronic claims submissions. Chapter 5, Claims Filing, Third-Party Resources, and Reimbursement, on page 5-1 for general information about claims filing. Section , CMS-1500 Claim Form Instructions, on page 5-21 for instructions on completing paper claims. Blocks that are not referenced are not required for processing by TMHP and may be left blank Reimbursement Diabetic equipment and supplies may be reimbursed based on the lower of the billed amount or the amount allowed by the Centers for Medicare & Medicaid Services (CMS), if available, or by Texas Medicaid TMHP-CSHCN Services Program Contact Center The TMHP-CSHCN Services Program Contact Center at is available Monday through Friday from 7 a.m. to 7 p.m., Central Time, and is the main point of contact for the CSHCN Services Program provider community. 15 CPT only copyright 2008 American Medical Association. All rights reserved. 15 7

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