Revised Billing Guidelines For Continuous Glucose Monitors (CGMs)

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Revised Billing Guidelines For Continuous Glucose
Monitors (CGMs)
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Revised Billing Guidelines For Continuous Glucose
Monitors (CGMs)
Medicare Coverage for Continuous Glucose Monitors
(CGMs) On December 28, 2021, the Centers for
Medicare Medicaid Services (CMS) published a
final rule in the Federal Register that addressed
the classification and payment of continuous
glucose monitors (CGMs) under the Medicare Part B
benefit for durable medical equipment (DME). This
rule expanded the classification of DME to a
larger group of CGMs, regardless of whether the
CGMs are non-adjunctive (can replace standard
blood glucose monitors for treatment decisions)
or adjunctive (do not replace standard blood
glucose monitors for treatment decisions). As
such, claims for adjunctive CGMs and related
supplies and accessories can now be covered under
the Part B DME benefit category when the system
meets the DME definition. Applicable Healthcare
Providers Applicable healthcare providers
include, 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. Billing Codes
for Continuous Glucose Monitors (CGMs) CPT
95249 Personal CGM Start-up and Training
Ambulatory CGM of interstitial tissue fluid via a
subcutaneous sensor for a minimum of 72 hours
patient provided equipment, sensor placement,
hook-up, calibration of monitor, patient
training, and printout of recording. Frequency
Once for the lifetime of the personal CGM device.
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Revised Billing Guidelines For Continuous Glucose
Monitors (CGMs)

• CPT 95250
• Professional CGM Ambulatory CGM of interstitial
  tissue fluid via a subcutaneous sensor for a
  minimum of 72 hours physician or other qualified
  health care professional (office) provided
  equipment, sensor placement, hook-up, calibration
  of monitor, patient training, removal of sensor,
  and printout of recording. Frequency Maximum of
  once per month.
• CPT 95251
• CGM Interpretation Ambulatory CGM of interstitial
  tissue fluid via a subcutaneous sensor for a
  minimum of 72 hours analysis, interpretation,
  and report.
• -25 Modifier
• Evaluation and Management (Separate Identifiable
  Service) An E/M CPT code can be billed on the
  same day as codes 95249, 95250, and/or 95251 if
  documentation supports the medical necessity of a
  significant and separately identifiable
  evaluation and management service performed the
  same date. Modifier 25 is added to the E/M code
  to report a significant and separately
  identifiable evaluation and management performed
  above the CGM services.

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Revised Billing Guidelines For Continuous Glucose
Monitors (CGMs)

• Applicable Insurance Carriers
• 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 above mentioned CPT codes. Although the
  coverage criteria may differ between personal and
  professional use of CGM, the payer coverage
  decisions have not differentiated CPT codes
  between personal and professional 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 95250 and 95251 may be
  covered. There is Medicare payment for CPT codes
  95250 and 95251 when billed for professional CGM
  only. Medicare does not currently cover personal
  CGM.
• We shared revised billing guidelines for
  continuous glucose monitors (CGMs) for reference
  only, still you can verify coding and payment
  with your local insurance carrier. Medisys Data
  Solutions is a leading medical billing company
  providing complete assistance in medical billing
  and coding. If you need any assistance in
  billing, contact us at info_at_medisysdata.com/
  302-261-9187

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