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. 

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

CPT code 95250 does not have any physician work RVUs (Relative Value Units); therefore the services associated with 95250 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 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.

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 is paid under Ambulatory Procedure Classification (APC) 5012 with 2017 national average payment of $106.

The Medicare fee schedules provided in the table above are national averages. Where would healthcare providers find the local Medicare fee schedules for physicians in their state?

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

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. +HCPs are not to use 95250 for personal use CGM for Medicare patients. It is the responsibility of the DME supplier to instruct beneficiaries on the use of Medicare covered items. If a physician or mid-level practitioner is 
interpreting the CGM data, they may be able to bill 95251. If a physician or mid-level practitioner has an office visit with patient to discuss treatment changes based on CGM results, they would bill E/M based on medical 
necessity and level of service provided. As always, we advise the office staff to consult with their payors for final coding advice.
1CMS-1654-CN3; Medicare Physician Fee Schedule Final Rule, Addendum B updates CY2017. Effective through December 31, 2017.
2CMS-1656-CN; Medicare Outpatient Prospective Payment System Final Rule, Addendum B updates CY2017. Effective through December 31, 2017.
3.PMIC Medical Fees in the United States 2017. Numbers provided are 50% of the Usual and Customary (UCR) charges. Note that these are charges and not actual reimbursed amounts.
4.Current Procedural Terminology (CPT®) Professional Edition 2017. Copyright 2016 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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