Medicare

Are other CGM products covered as well?

The ruling specifically states that only CGM products labeled as a replacement of fingerstick blood glucose testing for diabetes treatment decisions by the FDA and referred to in the ruling as “therapeutic CGM” will be covered. The Dexcom G5® CGM System was the first therapeutic CGM on the market. 

What should I do if I have Medicare patients that can benefit from using a CGM?

For patients who could benefit from CGM, you will be able to write orders for “therapeutic CGM” for your patients very soon. In the interim, you can send them to Dexcom and we will notify them as soon as Medicare begins processing. Patients can be directed to https://www.dexcom.com/lead/1 or they can also contact our customer service team at 1 (888) 738-3646 to speak to a customer service agent.

Can physician assistants prescribe Therapeutic CGM?

A physician assistant (PA) may provide the dispensing order and write and sign the detailed written order if they satisfy all the following requirements:

• They meet the definition of physician assistant found in §1861(aa)(5)(A) of the Act;
• They are treating the beneficiary for the condition for which the item is needed;
• They are practicing under the supervision of a Doctor of Medicine or Doctor of Osteopathy;
• They have their own NPI; and
• They are permitted to perform services in accordance with State law.  

Can a nurse practitioner or clinical nurse specialist prescribe Therapeutic CGM?

 A nurse practitioner or clinical nurse specialist may give the dispensing order and sign the detailed written order in the following situations: 

• They are treating the beneficiary for the condition for which the item is needed; 
• They are practicing independently of a physician; 
• They bill Medicare for other covered services using their own provider number; and 
• They are permitted to do all of the above in the State in which the services are rendered. 

Can physicians bill the CGM CPT code 95250 for personal use CGM systems under the Medicare rules?

No, healthcare professionals (HCPs) should not use CPT code 95250 (patient training, hook-up and calibration, sensor removal, data download) for personal use continuous glucose monitoring (CGM) for Medicare patients—this code can be used only for professional CGM services.  

If a physician or mid-level practitioner is interpreting personal or professional use CGM data they would bill under CPT code 95251. Services associated with CPT code 95251 may be a non-face-to-face service. 

What is the difference between the Medicare physician fee schedule and the outpatient diabetes center payment?

Medicare physician payments are fee schedules based on relative value units (RVUs). Hospital outpatient services are paid under the outpatient prospective payment system (OPPS). CPT code 95250 (for Professional CGM only) is paid under Ambulatory Procedure Classification (APC) 5012 with 2017 national average payment of $106.

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If you have diabetes and are interested in getting started with Dexcom CGM, please contact us here.

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