Coding & Reimbursement Diabetes

Yes. CPT code 95249 is the code for CGM technical services, including patient training, for Personal or Real-Time CGM where the patient owns the CGM equipment.

Medicare and most payers limit CGM coverage to patients with diabetes and some require documentation that a patient’s diabetes is uncontrolled. Specific ICD-10 diagnosis codes are listed in the coverage policy and may vary by payer.

CGM is not covered under the home care benefit, nor would separate reimbursement be available.

CGM services would not be separately reimbursed if performed in an assisted living or skilled nursing facility.

Codes 95249 and 95250 are not valued for physician work under RBRVS. For Medicare, the services may be performed by a trained RN, CDCES, LPN, or MA under physician supervision and direction, and may then be billed by the physician "incident to" the physician service. This is also generally true for private payers but some may have restrictions related to licensure. Providers should verify requirements with each payer.

Only a physician, Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist can perform the data analysis and interpretation service and only these types of providers may bill 95251.

Yes, it may be appropriate for an E/M code to be billed for services provided on the same day as for codes 95249, 95250 or 95251, if the E/M code services were medically necessary and distinct from the CGM services. For example Modifier -25 should be appended to the E/M code to identify it as a “significant, separately identifiable evaluation and management service” performed on the same day. Note that analysis and interpretation of the CGM data is counted toward code 95251 and may not be counted again for any E/M service.

For Personal CGM, code 95249 can be reported just once during the time the patient owns the specific receiver. Placing a new sensor or new transmitter does not qualify; the receiver must be new to report 95249. For Professional CGM, instructions in the CPT manual state that code 95250 cannot be billed more than once a month, but utilization limits may vary by payer. Some payers may limit to twice a year and others may only require medical necessity but not have amount limits. Similarly, for professional data analysis and interpretation, CPT limits reporting code 95251 to once a month but payers may have their own utilization limits.

If a pharmacy is a Part B Medicare provider, they may be able to bill for 95250. However, only a physician or mid-level practitioner can perform and bill for CPT code 95251.

It is important to document services that were provided, and if applicable, that a sensor did not last 72 hours. Some payers may suggest reduced service modifier such as -52 be used. As always, please check with your payer and their coverage rules.

Descriptor code for CPT code 95250 includes insertion as well as removal of the CGM sensor, so typically billing may be done after the patient has the sensor removed.

The date on which the provider performed the data analysis and interpretation and generated the report should be used as the date of service.

No. The data analysis and interpretation may be performed as a remote, non-face-to-face service. Note that 99091 cannot be billed separately with 95251.

Medicare has a 20% copayment for Professional CGM. Co-payments and deductibles will vary by payer.

Code 95250 for Professional CGM is not reimbursed separately to either a physician or hospital if performed during an inpatient stay. Physicians are precluded from billing 95250 because hospital staff, e.g., nurses, perform the technical services for CGM during an inpatient stay. For hospitals, reimbursement for these services would be included within the inpatient DRG or case-rate payment to the hospital. However, the professional data analysis and interpretation could be separately reimbursable to the physician if performed by the physician during the stay.

Yes, Medicare does cover and reimburse for Professional CGM (CPT code 95250) as well as the data analysis and interpretation (CPT code 95251).

Many private/commercial payers have established policies for Personal and Professional CGM. These payers include United Healthcare, Aetna and Cigna. Some payers list the CPT codes in their policies. The coverage criteria may differ between Personal and Professional CGM. For specific details, reference the payer’s policy for Continuous Glucose Monitoring. Verify coding and payment with your applicable payers.

It is important to understand why the claim was denied, as these denials can occur for several reasons. For example: confirm that the most appropriate and accurate diagnosis was billed. Check with the payer’s policy to verify that the amount of submissions for CGM services are within the payer’s specified limits. If the claim includes an E/M code for the same day, it may be appropriate to use modifier -25 on the E/M code to specify that the E/M code was a separate and identifiable service. Enter into a dialogue with your local payer to determine which options if any are available to address your claim question.

Yes. CMS wrote in the CY2018 PFS final rule 20 that they were requiring beneficiary consent, in advance, for anything billed with 99091. On a practical basis, this is because it's subject to a beneficiary co-payment and is a non-face-to-face service by nature, so the patient is likely to not know where the bill for the co-payment is coming from unless they've been asked for consent in advance. CMS did not specify how to collect patient consent in the final rule; it just said to document the consent in the medical record. Consider following the same process for collecting and documenting consent for other remote, non-face-to-face services.

No. There is a NCCI edit in place that does not allow for this billing scenario with no override allowed. If the services described by code 99091 are provided on the same date of service as an E/M visit, they are considered part of the E/M and are not reported separately. Factor the time spent on activities related to services described in 99091 into the reported level of the E/M service.

Code 99457 is defined for 20 minutes of time over the course of the month, and add-on code +99458 is defined for each additional 20 minutes. CMS clarified that the total time includes the cumulative time spent in interactive communications with the patient or caregivers as well as time engaged in non-face-to-face care management activities during the month. Clear documentation in the medical record of time spent is key. 

This is a bit of a gray area. Both the CPT manual and the Medicare Physician Fee Schedule Rules in the Federal Register refer to a requirement of 16 days of data in the context of the technical codes: 99453 and 99454. There may be an implication that the physician is then performing treatment management codes 99457 and +99458 based on the 16 days’ worth of data collected for 99453 and 99454. Very conservatively, you could restrict use of 99457 and +99458 to when treatment management is performed based on interpretation of 16 days’ worth of data, but there is no specific requirement. Always check with your individual payer. 

Codes 99457 and +99458 are defined for not only physicians and NPPs but also for "clinical staff." CMS classifies these codes as services that can be performed by auxiliary personnel under general supervision of the physician. So, an RD and a CDCES can make the phone calls and their time counts towards the total time. But only the physician or NPP can bill for these codes.⁹ Note that codes 99457 and 99458 are in the E/M section of the CPT manual, so only professionals who can bill E/M services can bill these codes. 

There are no specific CPT codes for insulin pump starts. Separate from an insulin pump start or related training, however, Evaluation and Management (E/M) codes may be appropriate if health care services were provided by a physician (or other practitioner) to a patient before, during, or after the training. In addition, diabetes education codes such as G0108 and G0109 (for certified diabetes education centers) or general education codes 98960-98963 may also be appropriate. Some non-Medicare payers may accept S9145, Insulin pump initiation, instruction in initial use of pump (pump not included).

It depends on the data being reviewed.

• Review and interpretation of CGM values in CareLink is appropriately reported with code 95251.
• Code 95251 is not appropriate for review and interpretation of pump values.

Providers may consider use of code 99091 for review and interpretation of pump values performed remotely. Payer policies may vary and providers should always verify coverage with the individual payer. Note that code 99091 can be billed only once a month and requires at least 30 minutes of cumulative provider time. Also note that codes 95249, 95250, and 95251 cannot be reported with 99091. Code 99091 is intended to represent a non-face-to-face service and cannot be assigned when pump values are reviewed during an office visit or in association with an office visit. When pump values are reviewed during an office visit or in association with an office visit, the service is included in the E/M assigned for the visit.

Yes. Coverage and coding for CGM does not typically differ by physician specialty.

Non-facility rates are for services provided in a physician office or similar setting, and facility fees are for services provided in a hospital (outpatient or inpatient) or similar institutional setting.

Yes, CMS has published the most recent Medicare Physician Fee Schedule at their website. They have created tool https://www.cms.gov/apps/physician-fee-schedule/overview.aspx to look up Medicare’s published fees for specific CPT and HCPCS codes.