O24.311 — Unspecified pre-existing diabetes mellitus in pregnancy, first trimester
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- CGM devices billed as HCPCS E2103 (and E2102 effective July 1, 2022) must have PDAC coding verification and be listed on the PDAC Product Classification List (PCL) for the respective HCPCS code prior to billing.
- For items subject to Final Rule 1713, a face-to-face encounter and a Written Order Prior to Delivery (WOPD) are required for specified HCPCS codes; claims without these will be denied as not reasonable and necessary and items delivered prior to receipt of a WOPD are ineligible for payment.
- If beneficiary utilization of BGM testing supplies exceeds usual amounts, the medical record must document an in-person or Medicare-approved telehealth visit evaluating diabetes control, that ordered quantities are reasonable and necessary, and that beneficiary testing frequency corroborates dispensed quantities (narrative or testing log).
Key Coverage Criteria
- Medicare may classify adjunctive CGMs as DME (since Feb 28, 2022) when LCD and statutory requirements are met.
- Home blood glucose monitors (BGMs) and continuous glucose monitors (CGMs) are covered under the Durable Medical Equipment (DME) benefit when the device and use meet the related LCD reasonable-and-necessary requirements and other Medicare statutory/regulatory requirements.
- Therapeutic (non-adjunctive) CGM devices that permit treatment decisions without confirmatory BGM are covered under DME.
- A CGM system supply allowance (HCPCS A4238 or A4239) is covered when the beneficiary uses a stand-alone durable CGM receiver or an insulin infusion pump classified as DME to display glucose data, or when a non-DME device is used in conjunction with a durable CGM receiver.
- For non-adjunctive CGM systems, the supply allowance (A4239) may include a home BGM and related supplies if clinically necessary.
- Removal of corns and calluses of the feet must be billed using CPT codes 11055-11057 (paring/cutting of benign hyperkeratotic lesion) and the procedure code that most accurately describes the service performed should be reported.
6 Active Policies
A52996 — Billing and Coding: Routine Foot Care
J12
L35138 — Routine Foot Care
J12
A52464 — Glucose Monitor - Policy Article
J19
ANTHEM-CG-RAD-26 — CG-RAD-26 Maternity Ultrasound in the Outpatient Setting
A56686 — Billing and Coding: HbA1c
Related Codes
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