Provider Alert! Continuous Glucose Monitor and Integrated Insulin Pump Equipment Change for Texas Medicaidtcph
Date: January 25, 2023
Attention: Primary Care Providers, Endocrinologists, and Diabetes Educators
Effective date: January 1, 2023
Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event. TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.
Call to action: Texas Children’s Health Plan (TCHP) would like to inform providers of new adjunct continuous glucose monitor (CGM) device and supply codes that went into effect January 1, 2023. Coverage details have been updated to align with the new procedure codes found in the 2023 Annual HCPCS update.
How this impacts providers: Major changes to this medical benefit include the following:
|Item||Former Codes||New Codes Effective 1/1/2023||Notes|
|Therapeutic CGM||K0554 (device) and K0553 (supplies)||E2103 (device) and A4239 (supplies)||Non-adjunctive, non-implanted only. Supply allowance for A4239 is 1 per 30 days.|
|Adjunctive CGM||A9276, A9277, and A9278 (procedure). Former procedure codes will become informational only.||E2102 (device) and A4238 (supplies)||Supply allowance for A4239 is 1 per 30 days. E2102 must be submitted with modifier KF* when submitting a claim for a class III (3) CGM device. No modifier is required when submitting a claim for class II (2) CGM device. The supply allowance for A4238 encompasses all items necessary for the use of the device and includes, but is not limited to: CGM sensors and transmitters. A4238 does not include a home blood glucose monitors (BGM) or related BGM testing supplies.|
|Adjunctive CGM-Integrated External Insulin Pump||E0874 (procedure) with modifier UD* E2102 (procedure) with modifier U4*||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||E0874 (procedure) with modifier UD* E2103 (procedure) with modifier U4*||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*.|
|Additional information for Adjunctive CRM:|
|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.|
|Additional information for 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.Requests for supplies for member -owned CGM devices require the ordering provider to submit a statement attesting that the member meets one of the following conditions: The member owns a CGM device, and the member’s current condition meets coverage criteria for a CGM; or The member owns a CGM device and is compliant with using the CGM device to manage their diabetes
|Additional information for CGM Integrated External Insulin Pumps|
|A CGM integrated pump (an insulin pump that has CGM capability) may be considered for reimbursement when the member 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 184.108.40.206.1, in the Texas Medicaid Provider Procedures Manual. When a CGM-integrated pump is covered, its supplies (procedure code A4238 or A4239) are also covered.|
|Limitations for CGM Pumps|
|Changes include the following: Only one CGM-integrated pump may be reimbursed for a qualified member 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 patient 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
Next steps for providers: Providers should share this communication with their staff and note that prior authorization is only required for E2103, therapeutic CGM receiver device.
If you have any questions, please contact TCHP Utilization Management at: 1-800-731-8527.