Policy Name: Continuous Glucose Monitoring System – Coding Guidelines Effective 02/01/2022
To avoid delays in claim processing, please refer to the following chart that identifies the appropriate HCPCS and modifier combinations that must be billed with a National Drug Code (NDC) to identify supplies covered under HMSA’s Continuous Glucose Monitoring System policy.
Please ensure that the applicable HCPCS and modifier is billed with the correct NDC. If no modifier, for preferred or preferred products (Freestyle Libre and Dexcom), or no NDC is billed, your claim will be returned for corrected billing.
| Service | CGMS | HCPCS Codes | Modifier (required) | Description | NDC (required) |
|---|---|---|---|---|---|
| Receiver, Sensor, and Transmitter |
Freestyle Libre (preferred) |
A9276 | KF | Sensor; invasive (e.g., subcutaneous), disposable, for use with interstitial continuous glucose monitoring system, one unit – 1/day supply | Yes |
| A9278 | KF | Receiver (monitor); external, for use with interstitial | Yes | ||
|
Dexcom (preferred) |
A9276 | U8 | Sensor; invasive (e.g., subcutaneous), disposable, for use with interstitial continuous glucose monitoring system, one unit – 1/day supply | Yes | |
| A9277 | U8 | Transmitter; external, for use with interstitial continuous glucose monitoring system | Yes | ||
| A9278 | U8 | Receiver (monitor); external, for use with interstitial continuous glucose monitoring system | Yes | ||
| Other than Freestyle Libre and Dexcom | A9276 | None | Sensor; invasive (e.g., subcutaneous), disposable, for use with interstitial continuous glucose monitoring system, one unit – 1/day supply | Yes | |
| A9277 | None | Transmitter; external, for use with interstitial continuous glucose monitoring system | Yes | ||
| A9278 | None | Receiver (monitor); external, for use with interstitial continuous glucose monitoring system | Yes |
Below are billing instructions for submitting the NDC information on an 837 electronic claim or a CMS-1500 hardcopy claim.
Electronic 837 submission
| Field | Electronic 837 version 5010 |
|---|---|
| NDC Qualifier |
Loop 2410 LIN02 (Product/Service ID Qualifier) |
| National Drug Code (NDC) |
Loop 2410 LIN03 (Product/Service ID) Format: XXXXXXXXXX (11 digits with hyphens omitted) |
| NDC Quantity |
Loop 2410 CTP04 (National Drug Unit Count) Numeric value of quantity dispensed |
| Unit of Measurement | Loop 2410 (NDC Unit of Measurement) |
CMS-1500 hardcopy submission
Specific data formats must be used when filling paper claims to ensure claims process accordingly. On the CMS-1500 form, indicate the NDC under the shaded area of Box 24D, see example below:
Revision History
| Date | Nature of Revision |
|---|---|
| 08/03/2026 | Migrated to new platform.
|