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.

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. 

Please note that CPT code 95250 cannot be used for personal CGM use under Medicare guidelines.

2017 Medicare Therapeutic Continuous Glucose Monitoring (CGM) Coding Reference

 

Abbreviations
APC - Ambulatory Payment Classification
CDE – Certified Diabetes Educator
CNS – Clinical Nurse Specialist
CPT – Current Procedural Terminology
E/M – Evaluation and Management
HCPCS - Healthcare Common Procedure Coding System
MA – Medical Assistant
MD – Medical Doctor
NP – Nurse Practitioner
PA – Physician Assistant
PharmD – Doctor of Pharmacy
RD – Registered Dietitian
RN – Registered Nurse
RPh – Registered Pharmacist
RVU – Relative Value Unit

 

†Non-facility is defined as office space.
‡HCPs are not to use CPT 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 a patient to discuss treatment changes based on CGM results, they would bill E/M based on medical necessity and level of service provided. Office staff should consult with their state's DME Medicare Administrative Contractor (MAC) for final coding advice.
§Visit the Centers for Medicare and Medicaid (CMS) for state and local fee schedules.
IIThese individuals may perform this service if within their scope of practice and billed by the supervising physician or hospital outpatient department.

FAQs

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.

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

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. 

If a physician or mid-level practitioner has office visits with a patient to discuss treatment changes based on personal or professional use CGM results, they should bill using Evaluation and Management (E/M) codes based on medical necessity and level of service provided. 

Office staff should consult with their payers for final coding advice.

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. 

A nurse practitioner or clinical nurse specialist may complete Section B and sign Section D of the Certificate of Medical Necessity (CMN) if they meet all the criteria described above for signing orders.

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.  

PAs may complete Section B and sign Section D of the CMN  if they meet all the criteria described above for signing orders.

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. As a reminder, the Medicare beneficiary may NOT use their phone either as a primary receiver or as a secondary device and still be eligible for Therapeutic CGM.

1CMS-1654-CN3; Medicare Physician Fee Schedule Final Rule, Addendum B updates CY2017. Effective through December 31, 2017.
2CMS-1656-CN; Medicare Outpatient Prospective Paymevtnt System Final Rule, Addendum B updates CY2017. Effective through December 31, 2017.

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