Billing for Continuous Glucose Monitor (CGM)

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Billing for Continuous Glucose Monitor (CGM)
On December 28, 2021, the Centers for Medicare
Medicaid Services (CMS) published a final rule
which was implemented on February 28, 2022. This
final rule addressed the classification and
payment of continuous glucose monitor (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 Procedure
Codes There are currently two Current Procedural
Terminology (CPT) codes for CGM 95250 and 95251.
CPT 95250 is used for the technical component of
Continuous Glucose Monitor and covers patient
training, glucose sensor placement, monitor
calibration, use of a transmitter, removal of a
sensor, and downloading of data.
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Billing for Continuous Glucose Monitor (CGM)
CPT code 95250 may be appropriate for
retrospective CGM and for the initial training,
hookup, download, etc. on patient-use CGM.  The
CPT code 95251 is for the analysis and
interpretation of CGM data. This analysis does
not need to be performed face-to-face with the
patient. However, CPT 95251 is a
professional code that is only billable by a
physician or midlevel provider (i.e., nurse
practitioner or physician assistant).
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Billing for Continuous Glucose Monitor (CGM)

• CPT 959250 code description Professional
  Continuous Glucose Monitor 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 a sensor, and printout of recording.
• CPT 95250 can be billed by any qualified staff
  member under the direct supervision of a
  physician, a physician assistant, or a nurse
  practitioner. 
• CPT 959251 code description CGM Interpretation
  Ambulatory CGM of interstitial tissue fluid via a
  subcutaneous sensor for a minimum of 72 hours
  analysis, interpretation, and report.
• CPT 95251 can be billed by Physicians, Physician
  Assistants, and Nurse Practitioners. 
• Modifier -25 An EM 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 on
  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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Billing for Continuous Glucose Monitor (CGM)

• Code limitations 
• CPT codes 95250 and 95251 are defined as a
  minimum of 72 hours neither code can be assigned
  or billed if a CGM of less than 72 hours is
  provided.
• CPT codes 95250 and 95251 cannot be reported more
  than once per month per patient regardless of the
  duration of professional CGM or the number of
  times CGM is provided in a single month.
• E/M can only be billed separately on the same day
  when a significant and separately identifiable
  service took place above and beyond the services
  associated with CGM.
• Use modifier -25 with E/M code when billing
  95250 and 95251 on the same day.
• Other Billing Details for CGM
• Document the primary diagnosis code and the
  appropriate ICD indicator based on the date of
  service. Example diagnosis code 250.03 (Diabetes
  without mention of complications type 1,
  uncontrolled. 
• Common ICD-10 codes include
• E10.649 Type 1 diabetes mellitus with
  hypoglycemia without coma
• E10.65 Type 1 diabetes mellitus with hyperglycemia

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Billing for Continuous Glucose Monitor (CGM)

• E10.69 Type 1 diabetes mellitus with other
  specified complications
• E10.8 Type 1 diabetes mellitus with unspecified
  complications
• E10.9 Type 1 diabetes mellitus without
  complications
• E11.649 Type 2 diabetes mellitus with
  hypoglycemia without coma
• E11.65 Type 2 diabetes mellitus with
  hyperglycemia
• E11.69 Type 2 diabetes mellitus with other
  specified complications
• E11.8 Type 2 diabetes mellitus with unspecified
  complications
• E11.9 Type 2 diabetes mellitus without
  complications
• E13.8 Other diabetes mellitus with unspecified
  complications
• E13.9 Other specified diabetes mellitus without
  complications
• Specify the location where the service was
  performed Examples include, POS 11 and POS Office
  22 for outpatient hospital
• Documentation It may vary as per payer but
  standard documentation for CGM includes the
  following
• Documented glycemic control problems 
• Description of a patient treatment plan 

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Billing for Continuous Glucose Monitor (CGM)

• Record of patients adherence to plan 
• Physician progress notes 
• Evaluations and consultations related to the
  diagnosis 
• Laboratory reports, including HbA1c
• Blood glucose logs 
• Physician report with interpretation and findings
  based on information obtained during monitoring
• Always verify benefits for every patient visit
  and check for requirements of the prior
  authorization request.
• Medical Billers and Coders (MBC) is a leading
  medical billing company providing complete
  revenue cycle services. To learn more about our
  medical billing and coding services, email us
  at info_at_medicalbillersandcoders.com or call us
  at 888-357-3226
• Reference  Continuous Glucose Monitoring (CGM)
  Understanding the Fundamentals