CMS details coverage, claims, and payment for diabetes supplies

CMS recently published an MLN fact sheet to detail Medicare Part B and D coverage, claims, and payment for diabetes supplies.

For Part B-covered durable medical equipment (DME), Medicare generally pays 80% of the Medicare-approved amount after the patient meets their deductible.

Although the amount depends on insulin usage, Part B covers the following blood glucose self-testing equipment and supplies for all diabetes patients:

• Blood glucose monitors
• Continuous blood glucose monitors
• Blood glucose test strips
• Lancet devices and lancets
• Glucose control solutions for checking the accuracy of testing equipment and test strips
• Supply allowance for a therapeutic continuous glucose monitor including all supplies and accessories

Part B also covers external durable insulin pumps and the insulin used with the pump. To ensure appropriate reimbursement, doctors should make certain their order specifically states that the insulin will be used with the pump, says CMS.

As of July 1, 2023, Part B coinsurance for insulin is limited to $35 per month. Organizations can bill a three-month supply of insulin with modifier JL or a one-month supply with modifier JK, according to a separate MLN fact sheet on Part B billing for insulin. These modifiers are to be billed with Healthcare Common Procedure Coding System codes J1817, J1811, and J1813.

Part B pays for one pair of therapeutic shoes and inserts per calendar year, and this payment includes the cost of fitting the equipment, according to the fact sheet.  

Part D covers injectable insulin not associated with the use of a durable insulin infusion pump and any other medications to treat diabetes at home that are on the plan’s formulary, according to the fact sheet. CMS recommends that doctors specify that this insulin is to be used in a disposable pump in their orders to ensure proper billing and avoid unnecessary denials.

Part D also covers diabetic supplies for the administration of insulin, including syringes, needles, alcohol swabs, gauze, and inhaled insulin devices.

Revenue integrity professionals should review both fact sheets for more information on DME coverage criteria and insulin billing practices.