Reimbursement

Commercial Reimbursement

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Significant progress has been made for coverage of continuous glucose monitoring (CGM) with both commercial health insurers and government-sponsored plans. Many of the reimbursement challenges experienced by the early-adopters of CGM no longer exist and today’s reimbursement environment has become more favorable. 

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Coverage

Coverage of CGM for type 1 diabetes is offered for 98% of commercially insured members, and many plans also provide coverage for members with insulin-using type 2 diabetes.**  Additionally, the Dexcom G5® CGM System is covered by Medicare.±

Select State

The letters below correspond to states. Make your selection for a listing of health care plans and their respective coverage criteria by state.

Coding

CGM has truly been a reimbursement success story. There are established CPT codes for providers to get paid and broad coverage within the payer community. Download the 2018 CGM Reimbursement reference sheet.

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What’s new in 2018?

A new code has been added: CPT code 95249 for personal CGM start-up and training. CPT code 95250 is now defined as start-up/training for professional CGM devices (CGM devices that were purchased by the clinic/practice for use with multiple patients). Additionally, CPT code 95249 can be billed for Medicare-eligible patients.

How often can CPT code 95249 be billed?

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.

What type of healthcare provider/physician can bill and perform CPT codes 95249, 95250 and 95251?

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.

Do services associated with CPT codes 95249 and 95250 need to be provided face-to-face?

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.4

If a patient starts using a Dexcom CGM System after previously using another manufacturer’s CGM system, can the HCP bill CPT code 95249 again?

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.

If a patient has been using their Dexcom receiver and then switches to a compatible smart device† to display their glucose data, can the provider bill CPT code 95249 for this training?

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 used to display glucose data.) However, providers should check with individual payers for specifics on billing when a patient switches to using a smart device for glucose data display.

Which insurance companies are paying for CPT codes 95249, 95250 and 95251? How do healthcare providers find out the specifics of each insurance company’s CGM coverage policy and criteria?

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.

What should practices do if they get denied for CPT codes 95249 and 95250?

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 are 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.

Please Note: The reimbursement information contained in the downloadable reference is intended to assist you with billing for your services related to continuous glucose monitoring (CGM). It is intended for informational purposes only and is not a guarantee of coverage and payment. Providers are encouraged to contact their local payers with questions related to coverage, coding and payment.

**Internal data on file.
±The beneficiary may NOT use their phone either as a primary receiver, or as a secondary device and still be eligible for therapeutic CGM.
For a list of compatible smart devices, please visit dexcom.com/compatibility
1 CMS-1676-FC; Medicare Physician Fee Schedule Final Rule, Addendum B updates CY2018. Conversion Factor 35.9996
2 CMS-1678-FC; Medicare Outpatient Prospective Payment System Final Rule, Addendum B updates CY2018. Fee schedules are national averages and are not geographically adjusted.
3 PMIC Medical Fees in the United States 2017. Numbers provided are 50% of the usual, customary and reasonable (UCR) charges. Note that these are charges and not actual reimbursed amounts.
4 CPT 2018 Professional Edition. (2017). Chicago, IL: American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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