Claim denials can occur for a wide variety of reasons. It is important to understand why the claim was denied and as appropriate, know what options are available to resubmit or appeal the claim. Confirm that the ICD-10 diagnosis code(s) are specific and valid for services provided and that the specific codes and services of CPT codes 95249, 95250 and 95251 are covered services within each health plan.

Ensure that frequency of submissions is within the specific insurance policy limits. Modifier -25 should be added to Evaluation and Management code (E/M) if billed on the same day as CPT codes 95249, 95250 and 95251. Modifier -25 verifies that the E/M service was separate and identifiable from the CGM service. For insurance plans requiring prior authorization, ensure that the authorization has been obtained prior to the service being performed.

The Center for Medicare and Medicaid (CMS) has a website where you can find state and local fee schedules for all CPT codes: https://www.cms.gov/medicare/physician-fee-schedule/search/overview

Medicare physician payments are fee schedules based on relative value units (RVUs). Hospital outpatient services are paid under the outpatient prospective payment system (OPPS).

The majority of commercial insurance plans have written positive coverage decisions for both personal and professional use of CGM. National payers such as Cigna, Humana, Aetna, United Healthcare and Anthem WellPoint are currently covering these CPT codes, although the coverage criteria may differ between personal and professional use of CGM. Coverage decisions may vary and limit coverage to specific patients (i.e. type 1) or may limit number of times per year CPT codes 95249, 95250 and 95251 may be covered. Work with your health plans to get copies of the most recent published CGM coverage decisions. As always, verify coding and payment with your local payers.

It is highly unlikely any commercial payers would cover training costs for devices that are not reimbursed. (Medicare does not currently reimburse for a CGM system if a smart device is solely used to display glucose data. The patient must have a receiver to use in conjunction with the smart device.) However, providers should check with individual payers for specifics on billing when a patient switches to using a smart device for glucose data display.

Yes, the code can be billed again for commercially-insured and Medicare patients if the patient is using a different manufacturer’s CGM system or a different model of a data receiver from the manufacturer’s CGM system they are currently using.

Yes, all of the services associated with CPT codes 95249 and 95250 must be provided face-to-face in order to bill for them. Services associated with CPT code 95251, however, may be a non-face-to-face service.¹

1 CPT 2019 Professional Edition. Chicago, IL: American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

CPT codes 95249 and 95250 do not have any physician work RVUs (Relative Value Units); therefore, the associated services can be performed by a trained RN, PharmD/RPh, RD, CDE or MA (if within their scope of practice) and billed by the supervising physician advanced practitioner or hospital outpatient department. However, only providers such as Physician (MD), Nurse Practitioner (NP), Physician Assistant (PA) or Clinical Nurse Specialist (CNS) can perform and bill for services associated with CPT code 95251.

This code can be billed only once during the time the patient owns the manufacturer-provided display device. This code may not be reported for subsequent episodes of data collection, unless the patient begins using a new generation of the manufacturer’s (or different manufacturer’s) CGM system or display device. Additionally, this code may not be billed unless at least 72 hours of CGM data is printed from the display device the patient was trained on.

If providers are performing remote monitoring beyond CGM, CPT codes 99091 or 99457 may be appropriate based on services provided. Providers should understand specific coverage criteria for billing remote monitoring (i.e. time required/frequency of billing/ patient consent).