February 8, 2023
What is new
Effective for date of services on or after January 1, 2023, benefits pertaining to continuous glucose monitor and integrated insulin pump equipment and supplies will change under Texas Medicaid. Full detailed information can be found in article 12/30/2022.
Overview of Benefit Changes
Major changes to this medical benefit include the following:
- New procedure codes for adjunctive continuous glucose monitors (CGMs)
- New procedure codes for CGM-integrated external insulin pumps with adjunctive CGM capability
- New benefit for CGM-integrated external insulin pumps with therapeutic CGM capability
Therapeutic CGM
The major changes for therapeutic CGM procedure codes:
- K0554 (device) replaced with E2103
- K0553 (supplies) replaced with A4239
Adjunctive CGM
Adjunctive CGM procedure codes A9276, A9277, and A9278 will become informational only, and they will be replaced by the following codes:
- Procedure code E2102 for the device – must be submitted with modifier “KF” for class III CGM
- Procedure code A4238 includes all items for use of the device and include CGM sensors and transmitters. It does not include a home blood glucose monitor (BGM) or related BGM testing supplies.
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
Since the following procedure codes will become informational Codes (A9276, A9277, and A9278) and insulin pump that has adjunctive CGM capability must be submitted using the following combination of procedure codes:
- E0784 with modifier UD*
- E2102 with modifier U4* for new adjunctive CGM device procedure code
Therapeutic CGM-Integrated External Insulin Pump
Insulin pump that has therapeutic CGM capability will become a new benefit and must be submitted using the following combination of procedure codes:
- E0784 with modifier UD*
- E2103 with modifier U4* for therapeutic CGM device procedure code
*Modifiers specific to fee-for-service claims processing
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.
Questions
Providers, for questions or additional information, please:
- Contact your BCBSTX Medicaid Network team at 1-855-212-1615
- Submit via email Texas Medicaid Network Department
The above material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment. References to other third-party sources or organizations are not a representation, warranty or endorsement of such organization. Any questions regarding those organizations should be addressed to them directly. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.