Home Blood Glucose
Monitors Medical Policy

From DMERC Medicare Advisory, September 1996, Region "C"

Coding guidelines

HCPCS codes A4254 and A4258 are valid only for dates of service on or after January 1, 1996.

Blood glucose test or reagent strips that utilize a visual reading and are not used in a glucose monitor should be coded A9270. Do not use HCPCS code A4253 for these items.

Documentation

An order for the billed equipment/supplies which has been signed and dated by the ordering physician must be kept on file by the supplier. The physician's order must include a statement indicating whether the patient is a diabetic and whether the patient is being treated with insulin injections. If the order indicates the patient is diabetic AND is being treated with insulin injections, the ZX modifier should be added to the HCPCS code for the monitor, and each related supply on every claim submitted. The ZX modifier may only be used when these requirements are met.

In addition, the medical necessity for EO609 must be documented by a narrative statement from the physician which includes the patient's visual acuity. If the claim is filed hard-copy, this could be noted in field 21 of the HCFA 1500 claim form or as a separate attachment. If the claim is filed electronically, it could be transcribed into the HAN record.

When billing for quantities of supplies greater than those described as the usual replacement frequency (e.g. more than lOO test strips or lancets per month), the claim must include documentation supporting the medical necessity for the higher utilization. This information should be attached to a hard-copy claim or entered in the HAD record of an electronic claim.

Refer to the Documentation section of the DMEPOS Supplier Manual for more information on orders, medical records and supplier documentation.

Effective date

Claims with dates of service on or after November 1, 1996. This is a revision to a previously published policy.

Subject: Home blood glucose monitors

HCPCS codes

The appearance of a HCPCS code in this section does not necessarily indicate coverage.

E0607-Home blood glucose monitor
E0609-Blood glucose monitor with special features (e.g. voice synthesizers, automatic timers, etc.)
A4244-Alcohol or peroxide, per pint
A4245-Alcohol wipes, per box
A4246-Betadine or pHisohex solution, per pint
A4247-Betadine or iodine swabs/wipes, per box
A4250-Urine test or reagent strips or tablets (100 tablets or strips)
A4253-Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips
A4254-Replacement battery, any type, for use with medically necessary home blood glucose monitor owned by patient, each
A4256-Normal, low and high calibrator solution/chips
A4258-Spring-powered device for lances, each
A4259-Lancets, per box of 100
A9270-Non-covered item or service
XX003-Platforms for home blood glucose monitor, 50 per box

HCPCS modifiers

ZX-Specific requirements found in the Documentation section of the medical policy have been met, and evidence of this is available in the supplier's records.

Benefit category

Durable Medical Equipment

Reference

Coverage Issues manual 60-11

Definition

Insulin-treated means the patient is receiving insulin injections to treat their diabetes. Insulin does not exist in an oral form and therefore patients taking oral medication to treat their diabetes are NOT insulin-treated.

Coverage and payment rules

Home blood glucose monitors are covered for patients who are insulin-treated diabetics and who can better control their blood glucose levels by frequently checking these levels and appropriately contacting their attending physician for advice and treatment.

A blood glucose monitor with special features is covered for patients who additionally have severe visual impairment (20/200).

Coverage of home blood glucose monitors is limited to patients meeting the following conditions:

  1. The patient must be an insulin-treated diabetic,
  2. The patient's physician states the patient is capable of being trained to use the particular device prescribed in an appropriate manner. In some cases, the patient may not be able to perform this function, but a responsible individual can be trained to use the equipment and monitor the patient to assure the intended effect is achieved. This is permissible if the record is properly documented by the patient's physician, and
  3. The device is designed for home rather than clinical use.

Blood glucose monitors with features such as voice synthesizers, automatic timers and specially designed arrangements of supplies and materials to enable the visually-impaired to use the equipment without assistance (E0609) are covered when the following conditions are met:

  1. The patient and device meet the three conditions listed above for coverage of standard home blood glucose monitors, and
  2. The patient's physician certifies he or she has a visual impairment severe enough to require use of this special monitoring system.

Lancets (A4259) and blood glucose test, reagent strips (A4253) and spring powered device for lancets (A4258) are covered for patients for whom the glucose monitor is covered. More than one spring powered device ( A4258) per 6 months will rarely be medically necessary. More than 100 test strips (A4253) and 100 lancets (A4259) per month will rarely be medically necessary. The need for more than these amounts should be documented in the physician's record and noted on the order kept on file by the supplier.

Alcohol or peroxide (A4244, A4245) and Betadine or pHisoHex (A4246, A4247) are non-covered since these items are not required for the proper functioning of the device.

Urine test reagent strips or tablets (A4250) are non-covered since they are not related to this equipment .

Glucose monitors and related supplies billed without a ZX modifier (see Documentation section) will be denied as not medically necessary.