CORRECT CODING – INSULIN USED WITH CONTINUOUS EXTERNAL INSULIN INFUSION PUMPS


DME MAC Joint Publication

Recently the DME MACs have become aware of pharmacy billing to Medicare Part D for insulin used in a Durable Medical Equipment (DME) external insulin infusion pump (E0784 [EXTERNAL AMBULATORY INFUSION PUMP, INSULIN]).  The DME MACs have jurisdiction for claims for DME and related supplies used with the DME items.  Payment under Part D is prohibited when there is coverage under a Part B benefit.  In the case of insulin, when it is administered via a Part B-covered DME pump, payment from Part D is excluded.  All claims for DME and supplies used with DME items must be billed to the DME MACs.

The correct HCPCS code to use for billing insulin used with an E0784 pump is:

J1817   INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS  

Use of HCPCS codes J1815 [INJECTION, INSULIN, PER 5 UNITS] or J7799 [NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH DME] are incorrect coding and will be denied.

Refer to the External Infusion Pump LCD, related Policy Article Standard Documentation Requirements article and DME MAC Supplier Manual for additional information on coverage, coding, documentation, and billing.

Correct coding is an essential element for correct claim payment.  The PDAC maintains a variety of resources to assist supplies in determining the appropriate code for Medicare billing. 

For questions about correct coding, contact the Pricing, Data Analysis, and Coding (PDAC) contractor Contact Center at (877) 735-1326 during the hours of 8:30 a.m. to 4:00 p.m. CT, Monday through Friday, or e-mail questions to the PDAC by completing the DME PDAC Contact Form.

Published by Noridian as the PDAC, November 2017.  Republished by Palmetto GBA as the PDAC January 2019.



Last Updated: 11/08/2017