May 5, 2021 - Updated June 15, 2021
Billing Reminders for Continuous Glucose Monitors (CGMs) Supply Allowance (K0553)
This article was updated and revised on June 15, 2021 to include the additional information about claim denial and the KS modifier.
Due to errors identified with recent claim submissions involving supplies used with therapeutic continuous glucose monitors (CGMs), CGS would like to issue several important reminders to suppliers.
Billing HCPCS K0553:
- Code K0553 describes a supply allowance used with a therapeutic CGM device.
- The supply allowance includes all items necessary for the use of the device. This includes but is not limited to CGM sensors, CGM transmitters, home blood glucose monitors (BGMs), related BGM supplies (test strips, lancets, lancing devices, and calibration solutions), and batteries. These items should not be billed separately.
- You can only bill 1 month of the supply allowance at a time.
- No more than 1 unit of service of HCPCS code K0553 is billable per 30 days.
- February does not have 30 days, so you must adjust your billing schedule if you bill on the same date each month.
KS, KX, and CG Modifiers:
- Use modifier KX if the beneficiary is insulin treated.
- Use modifier KS if the beneficiary is non-insulin treated. Note: If the beneficiary is non-insulin treated (KS modifier), the CGM device (code K0554) and the supply allowance (code K0553) will be denied as not reasonable and necessary.
- Use modifier CG only if all of the therapeutic CGM coverage criteria 1-6 in the Glucose Monitor Local Coverage Determination (LCD) (L33822)
are met.
- When LCD requirements are met, you must add the KX modifier and the CG modifier to both the CGM device (code K0554) and the supply allowance (code K0553).
- Do not use the KX modifier if the beneficiary is not being treated with insulin.
- Do not use the CG modifier if any of the coverage criteria are not met.
- You cannot use the KS and KX modifier at the same time.
CR Modifier:
- Refer to the Correct Use of the KX Modifier During the COVID-19 PHE and the COVID-19 web page for information about clinical indications of coverage not being enforced, specific to Therapeutic Continuous Glucose Monitors.
KF Modifier:
The KF modifier is a pricing modifier and must be appended to the CGM device (coded K0554) and the supply allowance (coded K0553) when the CGM is classified as a Class III device. If the CGM is not a Class III device, suppliers should not append the KF modifier to codes K0554 and K0553. Suppliers should contact the Pricing, Data Analysis and Coding Contractor (PDAC) for guidance on correct coding.
The scenarios below are examples for a supply allowance (K0553) associated with a CGM that is classified as a Class III device (KF modifier). The beneficiary is insulin treated (KX modifier), and all coverage criteria have been met (CG modifier).
Scenario 1 |
Scenario 2 |
Scenario 3 |
Scenario 4 |
DOS: 2/1/2021 (Paid) DOS: 3/1/2021 Solution: Resubmit with a date of service on or after 3/3/2021 |
DOS: 2/28/2021 (Paid) DOS: 3/29/2021 Solution: Resubmit with a date of service on or after 3/30/2021 |
DOS: 1/1/2021 (Paid) DOS: 1/31/2021 (Paid) Note: 30 days between billing |
DOS: 3/1/2021 (Paid) DOS: 4/1/2021 (Paid) Over 30 days between billing |
Refill Requirements:
Standard refill requirements are not applicable for the supply allowance (code K0553). This means the supplier does not have to specifically track how many single items or days' worth of supplies the beneficiary currently has on hand. Instead, if the DME supplier provides more than a one full month, 30-day supply of all necessary supply items, they must verify that the beneficiary has enough supplies to last the entire one full month, 30 days, before filing the next supply allowance claim (code K0553).
Please refer to the Local Coverage Article: Glucose Monitor – Policy Article (A52464) for complete information about payment rules, policy specific documentation requirements, modifiers, and coding guidelines for these items.