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. 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).
- 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.
- 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
- 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 example includes, 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
- Record of patient’s 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.
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