Effective Date: January 1, 2017

Purpose:

This policy provides guidelines for reimbursement of diabetic supplies when the utilization of these supplies is at a frequency over the usage listed by the supply code in the utilization guidelines. 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:

Products included:

• NJ FamilyCare/Medicaid
• Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP)

Definitions:

• 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.

Policy:

Horizon NJ Health deems that 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. Alternatively, modifier –EY can be used if no physician or other licensed health care provider orders exists. 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 an ICD 10 diagnosis code 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 member 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 member is actually testing at a frequency that corroborates the quantity of supplies that have been dispensed. If the member is regularly using quantities of supplies that exceed the utilization guidelines, new documentation must be present in the physician's records at least every six months.

If there is an appeal from a durable medical equipment vendor, then the physician's order, or any other document from the physician, which validates the patient uses more supplies than outlined in the utilization guidelines and indicates the quantity needed, will be considered as appropriate documentation. This is just documentation for appeal consideration, not a guarantee of payment.

Procedure:

Horizon NJ Health will deny claim lines containing diabetic supply codes submitted prior to the determined renewal interval.

Horizon NJ Health will also deny those claim lines where the quantity of the diabetic supplies is greater than the maximum allowed number of units under the utilization guidelines.

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.

Additional modifier criteria:

• 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.

Diabetic Supplies Utilization Guidelines:

* Not available for non-insulin dependent patients.

Examples:

• 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.

If none of the below ICD 10 diabetic diagnosis codes are present, the claim line will be denied.

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

References:

CMS Local Coverage Determination (LCD) L33822 “Glucose Monitors”
https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=33822

American Medical Association, Current Procedural Terminology (CPT®) Professional Edition and associated publications and services

Limitations and Exclusions:

Notwithstanding the foregoing, all payment determinations are subject to all other, applicable limitations, including but not limited to, the following:

• Benefit Limitations;
• The terms of any applicable provider participation agreement;
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
• Medical necessity; and
• Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.

CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. The CPT codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.