Professional CGM is a reimbursable procedure with broad coverage for people with diabetes*

transparent

88%

of commercial lives are members of a plan with written pro-CGM coverage1

transparent

100%

of fee-for-service Medicare patients have pro-CGM coverage2†

Coverage is limited to patients for whom professional CGM is medically necessary. Individual plan coverage may vary. Always verify coverage criteria and frequency directly with the payer.

Medicare does not have a NCD for professional CGM. Most local contractors do not have a policy limiting professional CGM. To determine coverage, check with the lcoal Medicare administrative contractor.

Reference:
  1. Data on file. Analysis by Policy Reporter.
  2. https://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx, accessed Aug, 2016
orange triangle
yellow triangle

Professional CGM Coverage Lookup*

Select State

Coverage information as of :

09/01/2016

*Not a guarantee of coverage under any specific plan. Coverage criteria are subject to change. Each payer may have multiple plans with different coverage. This information may not be complete or error-free and should be considered a guide only. To confirm coverage and frequency limits in individual cases, or for more information on any particular plan, you (or the patient) should contact the payer directly. This material was compiled based on publicly available information provided by Policy Reporter. Policy Reporter and its affiliates do not guarantee the accuracy or completeness of its service, data, or any content therein.

The information above reflects coverage only for approved indications of FreeStyle Libre Pro, and is not intended to give complete CGM coverage information. FreeStyle Libre Pro is NOT indicated for pediatric or gestational patients.

ƗFor the  “T1 (type 1 patients)”  and “T2 (type 2 patients)” categories: §For the “Prior authorization required” category:

    Y (yes) = Plan includes coverage in at least some cases

    N (no) = Plan does not include coverage

    U (unknown) = Contact the plan for information

      Y (yes) = Plan requires prior authorization for at least some cases

      N (no) = Plan does not require prior authorization

      U (unknown) = Contact the plan for information

Professional CGM Workflow & Associated Billing Codes

STEP
1

PATIENT SELECTION  
HCP prescribes pro-CGM
Patient in office*

VERIFY INSURANCE BENEFITS 
(Submit prior authorization if required)

SCHEDULE VISIT

STEP
2

BEGIN ASSESSMENTInsert sensor Educate patient Patient in office*

DATA COLLECTION
(Must collect at least 72 hours of device data to bill CPT 95250)

ASSESSMENT COMPLETE
Remove sensor Download data Generate reports Patient in office*

STEP
4

HCP TREATMENT RECOMMENDATION & PATIENT CONSULTATION Share evaluation results
Discuss therapy options Patient in office*

 Notes:
  • 95250 and 95251 can only be reported once monthly per patient and require a minimum of 72 hours of data. Payers are not obligated to cover monthly.
  • 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.

Individual plans vary. Always verify coverage and frequency limits directly with the payer. It is the physician's responsibility to ensure appropriate code selection.

*Billing of CPT 95250 and 95251 does not preclude the use of Evaluation and Management codes. Add modifier "-25" to the E/M code

if a separate face-to-face office visit above and beyond the CGM service is performed, medically necessary, and documented.

blue triangle
yellow triangle

Reimbursement

CY 2016 National Payments for CPT ® Codes 95250 and 95251

Definition

95250

Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; sensor placement, hook-up, calibration of monitor, patient training, removal of sensor, and printout of recording

(Do not repeat more than once per month.)

  • Medicare physician fee schedule1,2
  • Medicare allowable

$159.69

  • Private payer3
  • Median billed

$303

Definition

95251

Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; interpretation and report

  • Medicare physician fee schedule1,2
  • Medicare allowable

$44.04

  • Private payer3
  • Median billed

$87

Medicare rates are not geographically adjusted and do not show the impact of the 2% sequestration.

Physician fee schedule rates represent the non-facility allowed rates.


References: 1. Determining Medicare Payments PPRRVU16_V0122.xlsx https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/ 2. January 2016 Web Addendum B.12.14.15.xlsx https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/ 3. PMIC Medical Fees in the United States 2016. Numbers provided are the 50th percentile of the Usual and Customary (UCR) charges. Note: These are charges and not actual reimbursed amounts. Private payer paid rates are confidential.


CPT code definitions sourced from American Medical Association CPT Code Book 2016.
CPT is a registered trademark of the American Medical Association.

Reimbursement support

Download the Professional CGM Reimbursement Guide

Reimbursemnt support

Get ICD-10 code descriptions

To confirm local Medicare policies

Medicare Coverage Database

CMS Physician Fee Schedule Look-up Tool

Abbott Diabetes Care Reimbursement Customer Support

For reimbursement support, call 877-549-9181 between 8am-8pm EST

orange triangle