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)
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.
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.
CGM Interpretation Ambulatory CGM of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; analysis, interpretation, and report.
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.
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 firstname.lastname@example.org/ 302-261-9187