The increasing popularity of semaglutide, marketed as Ozempic and Wegovy, for both type 2 diabetes management and weight loss has led to numerous questions regarding proper coding and billing practices. This article aims to provide a detailed overview of the relevant CPT codes, ICD-10 codes, and considerations for healthcare providers when prescribing and administering Ozempic.
Introduction to Semaglutide and Its Uses
Semaglutide is a glucagon-like peptide-1 receptor agonist (GLP-1 RA) that affects appetite, digestion, and blood sugar levels. Originally approved for managing type 2 diabetes, it has also gained recognition for its effectiveness in weight management for adults with a BMI over 30. The medication is available only with a prescription, and its use requires careful monitoring and management by healthcare professionals.
Addressing the Semaglutide Shortage
In 2022, a surge in demand for semaglutide for weight loss led to a shortage. To address this, the FDA temporarily allowed compounded versions of the drug. However, in February 2025, the FDA announced that manufacturing capabilities had increased sufficiently to meet the demand, effectively ending the shortage. Now that the FDA has officially declared the semaglutide shortage over, patients and prescribers across the country are back to relying on Novo Nordisk to supply the diabetes and weight-loss medication.
Prescribing Semaglutide: Key Considerations
When considering semaglutide for patients, providers must adhere to a clear, documented process to ensure patient safety and minimize liability. This process should include:
- Comprehensive Initial Exam: A qualified medical provider should perform a thorough examination that goes beyond just BMI assessment. It's crucial to treat the individual, not just the condition.
- Patient Education: Educate patients thoroughly about the treatment, including potential side effects, lifestyle modifications, and the importance of long-term management.
- Long-Term Plan: Develop a sustainable plan to help patients maintain progress, emphasizing that weight loss treatment is not a one-time solution.
- Lifestyle Integration: Encourage regular exercise and collaboration with dietitians and nutritionists to provide ongoing nutritional support. Semaglutide's appetite-suppressing quality means the typical patient will consume fewer calories.
- Insurance Prequalification: Verify insurance coverage before starting treatment, as costs can be substantial, even with insurance. Payment installment plans can make treatment more affordable.
CPT Coding for Ozempic Administration
When a patient brings in their Ozempic pen for injection at the office, determining the appropriate CPT code can be complex. Here's a breakdown of the factors to consider:
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- Office Visit: Billing solely for a 99211 code (brief office visit) may not be sufficient.
- Education and Training: If the provider educates the patient on self-injection techniques, especially during the initial dose, billing for an office visit that includes education on the new medication is appropriate. Usually the idea is for the provider to see the pt do the first injection and then the patient does it moving forward at home.
- E/M Code: An Evaluation and Management (E/M) code (e.g., 99212-99215, depending on the level of service) should be used to reflect the complexity of the visit.
ICD-10 Coding for Ozempic
The ICD-10 code should reflect the primary reason for prescribing Ozempic. Common scenarios include:
Type 2 Diabetes: When Ozempic is used for diabetes management, the appropriate ICD-10 code should be used.
- E11.9: Type 2 diabetes mellitus without complications
- E11.8: Type 2 diabetes mellitus with unspecified complications
- E11.65: Type 2 diabetes mellitus with hyperglycemia
Weight Loss: When Ozempic is prescribed off-label for weight loss, the coding can be more complex.
- E66.0: Obesity due to excess calories (BMI ≥ 30)
- E66.01: Morbid (severe) obesity due to excess calories (BMI ≥ 30)
- E66.09: Other obesity due to excess calories (BMI ≥ 30)
It is important to note that listing obesity as the primary condition can lead to an automatic and immediate Ozempic prior authorization request denial.
The Role of Z Codes
Z codes represent reasons for encounters and should be accompanied by a corresponding procedure code if a procedure is performed.
Read also: CPT Coding for Weight Management
- Z79.85: Long-term (current) use of injectable non-insulin antidiabetic drugs. Report this code only when Ozempic is being used for diabetes.
When an obese patient is prescribed Wegovy for weight loss, but does not have diabetes, it is important to consider the implications of adding Z79.85. The coding guidelines reference them in the diabetes section. I am not saying one way is right or wrong, I am just asking for clarity.
Prior Authorization for Ozempic
Prior authorization (PA) is almost always required for insurance to cover Ozempic (semaglutide). Understanding those requirements in advance is a key step to getting your prior authorization for Ozempic approved.
Steps to Obtain Prior Authorization
Inquire with Insurance: Call the patient's insurance provider to determine if Ozempic is on their drug formulary and to obtain specific prior authorization criteria. It is also worth asking for their Mounjaro prior authorization criteria as well.
Gather Necessary Information: Ensure the doctor has all required information for the prior authorization request, including:
- Clinical criteria demonstrating medical necessity
- History of weight loss medications tried
- Proof of diet and exercise as adjuncts to medication
- Clinical progress while using Ozempic (if applicable)
- Prescribed Ozempic dosage
Monitor PA Status: Check the status of the prior authorization request through the insurance's online portal or by phone.
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Appeal Denials: If the prior authorization is denied, submit an appeal. The appeal should address the reasons for denial and provide additional supporting documentation.
Common Reasons for Denial and How to Appeal
- Not Covered on Formulary: If Ozempic is not on the insurance plan's formulary, request a "formulary exception" within the appeal.
- Missing Type 2 Diabetes Diagnosis: Provide detailed medical history to demonstrate the necessity of Ozempic, particularly if prescribed off-label for weight loss. If seeking treatment for weight loss, you can ask your doctor to submit a Zepbound prior authorization request or Wegovy prior authorization request.
- Step Therapy Requirements: If the insurance requires trying cheaper medications first (e.g., metformin, Victoza, Rybelsus, or Trulicity), document previous attempts and their outcomes.
- Quantity Limit: Verify the dosage and number of fills in the request and clarify any discrepancies with the insurance plan.
Clinical Criteria for Prior Authorization
All Ozempic prior authorization requests include a section for ‘Clinical Criteria’, which might also be referred to as Diagnosis or Medical Information. The goal of this information is to prove that you meet the clinical (medical) necessity requirements for Ozempic.
- Primary reason (condition) for Ozempic treatment. This is referred to as the ‘Diagnosis Code’ within a prior authorization request and indicates the specific condition or diagnosis for which Ozempic is being prescribed to treat. The ICD-10 code that best describes your condition.
- Diabetes & obesity-related clinical diagnoses. In this section, any comorbid diagnoses that have been caused by or are related to diabetes or obesity should be included.
- Diabetes medication history. In this section, any diabetes medications you have tried prior should be reported, such as Metformin, Rybelsus, Victoza, Sulfonylureas, Thiazolidinediones (TZDs), DPP-4 inhibitors or SGLT-2 inhibitors. Insurance may deny prior authorization for Ozempic if you haven’t tried cheaper medications options first, which is a policy commonly referred to as ‘step therapy’.
- Diet & exercise routine. Ozempic is indicated an an adjunct to a reduced-calorie diet and increased physical activity for the treatment of diabetes, which means thats prior authorization for Ozempic frequently asks for confirmation that you are currently on a calorie-restricted diet and are physically active.
Telemedicine and Online Prescriptions
Semaglutide can be legally prescribed online, provided the provider has prescriptive authority and meets the same standard of care as in-person visits. Some states may require a documented relationship between the patient and the prescribing provider.
Advertising Regulations
Clinics and med spas offering semaglutide for weight loss must adhere to strict state and federal advertising regulations. Marketing materials that mention drugs by name must be accurate and truthful.