Hospitals treating patients with insulin-dependent diabetes mellitus are preparing for billing and coding changes for intravenous insulin therapy.
Outpatient intravenous insulin therapy (OIVIT) describes an outpatient regimen performed in intermittent episodes that includes pulsatile or continuous intravenous infusion of insulin regulated by respiratory quotient, urine urea nitrogen (UUN), arterial, venous, or capillary glucose, or potassium concentration measurements. OIVIT is also known as cellular activation therapy (CAT), intercellular activation therapy (iCAT), chronic intermittent intravenous insulin therapy (CIIIT), hepatic activation therapy (HAT), metabolic activation therapy (MAT), pulsatile intravenous insulin therapy (PIVIT), pulse insulin therapy (PIT), and pulsatile therapy (PT).
Outpatient intravenous insulin treatment sessions may be provided in an outpatient or inpatient setting and typically entail using a specialized pump controlled by a computer program that adjusts the insulin dosages as determined by frequent blood glucose monitoring. The patient receives intermittent pulses of insulin through an intravenous catheter in a peripheral vein in the hand or arm over a six- to seven-hour period. The pulses are designed to deliver a higher concentration of insulin to the liver than subcutaneous injections. Chronic intermittent intravenous insulin treatment is usually performed as a weekly procedure in conjunction with daily subcutaneous insulin.
Many third-party payers do not cover intermittent intravenous insulin therapy. For example, under Blue Cross and Blue Shield coverage guidelines, all diagnoses for chronic intermittent intravenous insulin therapy are considered experimental or investigational and therefore are not covered. WellCare Health Plans’ coverage guideline on CIIIT for type 1 diabetes mellitus also considers the service experimental and investigational and not a covered benefit for the management of diabetes mellitus and other indications. Aetna’s clinical policy also classifies intermittent intravenous insulin therapy as experimental and investigational for the management of diabetes mellitus and all other indications, with the exception of diabetic ketoacidosis or hyperosmolar coma. In addition, the diagnostic tests of respiratory quotient, urine urea nitrogen, blood glucose, or potassium are also considered experimental and investigational when performed in the context of intermittent intravenous insulin therapy. According to Oxford’s policy, continuous intermittent intravenous insulin therapy is considered to be not medically necessary due to insufficient clinical evidence and will not be reimbursed.
Services making up an OIVIT regimen are noncovered under Medicare. On December 23, 2009, the Centers for Medicare and Medicaid Services (CMS) issued a noncoverage decision on OIVIT with an implementation date of March 8, 2010. According to CMS, evidence does not support the medical efficacy of OIVIT or the diagnostic tests performed in the context of OIVIT as reasonable and necessary to treat diabetes or any other medical condition.
CMS updated the Part B hospital (including inpatient hospital Part B and outpatient prospective payment system) chapter of the Medicare Claims Processing Manual (chapter 4, sections 320, 320.1, 320.2) with Transmittal 1913 dated February 5, 2010. Transmittal 112, also issued on February 5, revises the Medicare National Coverage Determinations Manual (chapter 1, part 1, sections 10–80.12 40.7, Outpatient Intravenous Insulin Treatment, effective December 23, 2009.
A new HCPCS code will be implemented with the April 2010 Integrated Outpatient Code Editor (IOCE) and Medicare physician fee schedule (MPFSDB) for use with this noncoverage decision:
- G9147 Outpatient intravenous insulin treatment (OIVIT) either pulsatile or continuous, by any means, guided by the results of measurements for: respiratory quotient; and/or, urine urea nitrogen (UUN); and/or, arterial, venous or capillary glucose; and/or potassium concentration)
Previously, HCPCS code 99199 Unlisted special service, procedure, or report, has been used to report an OIVIT regimen; however, effective April 5, 2010, Medicare claims for OIVIT or any services making up an OIVIT regimen billed with code 99199 will be returned to the provider as unprocessable. For dates of service on or after April 5, 2010, code G9147 should be reported on claims for noncovered OIVIT and any services making up an OIVIT regimen. Providers with Medicare claims for OIVIT with dates of service between December 23, 2009, and April 5, 2010, may bring these claims to their contractor’s attention for possible adjustment.
For specific coverage and claims processing instructions, see Pub. 100-03, NCD Manual, section 40.7, and Pub. 100-04, Claims Processing Manual, chapter 4, section 320 on the CMS website http://www.cms.hhs.gov. The CMS decision memo can be found at: http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=231. The links to the related transmittals are: http://www.cms.hhs.gov/transmittals/downloads/R112NCD.pdf and http://www.cms.hhs.gov/transmittals/downloads/R1913CP.pdf.
Sarah A. Serling, CPC, CPC-H, CPC-I, CCS-P, CCS