Insulin Used with Continuous External Insulin Infusion Pumps - Correct Coding - Revised

DME MAC Joint Publication

Recently the Durable Medical Equipment (DME) Medicare Administrative Contractors (MACs) have become aware of an issue with pharmacies billing to Medicare Part D for insulin used in a DME external insulin infusion pump (E0784 EXTERNAL AMBULATORY INFUSION PUMP, INSULIN). The DME MACs have jurisdiction for DME and related supplies used with the DME items. Payment under Part D is prohibited when there is coverage available under a Medicare Part B benefit. In the case of insulin, when it is administered via a Part B-covered DME pump, the insulin is considered a supply used with the DME pump. Therefore, payment from Part D is excluded. All claims for DME and supplies used with DME (such as insulin) 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) to bill for insulin that is used with a covered-durable medical pump, represents 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 Pricing, Data Analysis and Coding (PDAC) contractor maintains a variety of resources to assist suppliers in determining the appropriate code for Medicare billing. For questions about correct coding, contact the PDAC HCPCS Helpline at (877) 735-1326 during the hours of 9:30 am to 5:00 pm ET, Monday through Friday.  You may also visit the PDAC website to chat with a representative, or select the Contact Us button at the top of the PDAC website for email, FAX, or postal mail information.