Reimbursement

Medicare Reimbursement

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Medicare Coverage for Therapeutic CGM

In 2017, the Centers for Medicare and Medicaid Services (CMS) made a milestone ruling, establishing benefit coverage for “therapeutic CGM”—a designation applying only to those continuous glucose monitoring (CGM) systems approved for use in making diabetes treatment decisions without a fingerstick (“non-adjunctive use”).* The Dexcom G5® CGM System is the first therapeutic CGM system covered as a Medicare benefit.

NEW! Medicare coverage now includes mobile device usage. Learn more.

View Coverage  |  View Coding

*Fingersticks required for calibration of Dexcom G5, or if symptoms or expectations do not match readings, or when taking medications containing acetaminophen.

Coverage Requirements

To qualify for coverage of therapeutic CGM, Medicare patients with type 1 and type 2 diabetes on intensive insulin therapy who meet the following criteria may be able to obtain reimbursement:

  • The beneficiary requires a therapeutic CGM. The beneficiary has diabetes mellitus; and,
  • The beneficiary has been using a home blood glucose monitor (BGM) and performing frequent (four or more times a day) BGM testing; and,
  • The beneficiary is insulin-treated with 3 or more daily injections (MDI) of insulin or a continuous subcutaneous insulin infusion (CSII) pump; and,
  • The beneficiary's insulin treatment regimen requires frequent adjustments by the beneficiary on the basis of therapeutic CGM testing results.
  • Within six (6) months prior to ordering the CGM, the beneficiary had an in-person visit with the treating practitioner to evaluate their diabetes control and determine that the above criteria are met; and,
  • Every six (6) months following the initial prescription of the CGM, the beneficiary has an in-person visit with the treating practitioner to assess adherence to their CGM regimen and diabetes treatment plan

Coding

Refer to the chart below for Medicare billing codes for CGM. 

2018 Medicare Therapeutic Continuous Glucose Monitoring (CGM) Coding Reference

CGM Medicare Billing FAQs

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.

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. 

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). 

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


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

See all Medicare FAQS

Please Note: The reimbursement information provided here 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 verify the reimbursement rules applicable to them and to contact their local payers with questions related to coverage, coding and payment.

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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