REIMBURSEMENT

REIMBURSEMENT FOR

iPro

™

Professional Continuous Glucose Monitoring (CGM)

TARGET AUDIENCE:

The audience for this section is physicians, billing specialists, office managers and other office staff involved in coding, coverage and payment collection for Professional CGM services.

READERS WILL RECEIVE GUIDANCE ON:

• Proper coding for

iPro CGM

• The appropriate use of modifiers for

iPro Professional CGM

• Payor coverage criteria for

iPro Professional CGM

• Tips and tools to bill efficiently and correctly for

iPro Professional CGM

• Tips and tools on the prior authorization and appeals processes

ASSESSMENT:

iPro CGM Reimbursement

YES NO

Does your practice understand CPT codes for

iPro CGM?

Do you have a dedicated person in your office to work with payors?

Do you know which payors in your area cover

iPro CGM?

Does your practice periodically re-assess its processes for prior-authorization and denial management?

Does your billing manager understand payors' requirements for authorization

Does your practice routinely audit your billing process for

iPro CGM?

Use this assessment to identify your practice’s successes and oppor tunities in handling reimbursements with payors. Where the answer is “no”, look for ways to make changes or improvements in your diabetes practice’s processes and staff training.

PRACTICE GUIDE

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DM, TYPE I, controlled (see #1 - 3) 250.01

DM, TYPE I, uncontrolled (see #1 - 3) 250.03

DM, TYPE II, controlled (see #1 - 3)

DM, TYPE II, uncontrolled (see #1 - 3)

250.00

250.02

733.00

PATIENT AGE _______________

(If female & > 65 yrs, see #4)

Osteoporosis (See #4-7)

Pregnancy with Diabetes (See #1-3) 648.0*

Pregnancy w/Gest DM (See #1-3) 648.8*

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REIMBURSEMENT

CODING, COVERAGE AND PAYMENT

R e i m b u r s e m e n t h a s t h re e co m p o n e n t s : co d i n g, cove r a g e a n d p ay m e n t . This section discusses coding, coverage and payment as it relates to professional CGM.

Coding Coverage Payment

Classifies patient conditions, services, and supplies

Defines products and services that are eligible for payment

Represents the dollar amount(s) paid for services

CODING:

Current Procedural Terminology (CPT®) codes provide a uniform language for physicians to bill their services to payors. CPT codes are not technology specific, and are used to describe medical services by healthcare providers in all care settings. There are two CPT codes specific for continuous glucose monitoring, 95250 and 95251. The latest (2009) American Medical Association (AMA) descriptors for these codes are as follows

• 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 report 95250 more than once per month

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• 95251: Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; interpretation and report

Do not report 95251 more than once per month

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1

Note: Once per month reporting is per patient

2

Note: Once per month reporting is per patient

®CPT codes, and descriptions and other data only are copyright 2008 American Medical Association (® or such other date of

publication of CPT). All Rights Reserved. CPT® is a registered trademark of the American Medical Association (AMA)

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PRACTICE GUIDE

DM, TYPE I, controlled (see #1 - 3) 250.01

DM, TYPE I, uncontrolled (see #1 - 3) 250.03

DM, TYPE II, controlled (see #1 - 3)

DM, TYPE II, uncontrolled (see #1 - 3)

250.00

250.02

733.00

PATIENT AGE _______________

(If female & > 65 yrs, see #4)

Osteoporosis (See #4-7)

Pregnancy with Diabetes (See #1-3) 648.0*

Pregnancy w/Gest DM (See #1-3) 648.8*

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REIMBURSEMENT

For Professional CGM, both CPT codes 95250 and 95251 may be billed more than once per patient per year depending on payor coverage. This may apply when it is medically necessary for multiple

Professional CGM evaluations on a patient in a given year. Verify specific coverage criteria directly with the payor.

In 2009, the AMA made several changes to CPT codes 95250 and 95251. The descriptors for these CPT codes changed from “up to 72 hours” to a “minimum of 72 hours”. The second change was the addition of the statement “Do not report more than once per month” to both CPT codes 95250 and 95251. The addition of the statement “Do not report more than once a month” was to clarify that these codes are not to be billed more than once a month per patient.

These coding changes are positive and ensure that the CGM codes continue to reflect prevailing use of the technology. However, coding changes do not obligate payors to increase their coverage for CGM. Payors are NOT obligated to pay for these codes, and payors continue to determine their own frequency limits and coverage criteria for CGM-related services .

CPT CODE 95250

Who can perform and bill CPT code 95250?

Services associated with CPT code 95250 can be performed by any qualified healthcare provider

(consistent with state licensing requirements), including physicians, physician assistants, nurse practitioners, certified diabetes educators (CDEs), registered and licensed practical nurses, registered dietitians (RDs), medical assistants (MAs) or laboratory technicians, consistent with state scope of practice laws.

The services associated with CPT 95250 do not have to be performed by a physician or mid-level practitioner. As with other medical services, CPT 95250 can only be billed by a provider contracted with the patient’s health plan.

Physician offices bill CPT 95250 on a standard CMS-1500 claim form. When billed by a mid-level practitioner, the payment is typically 85 percent of the allowable reimbursement for physicians.

Diabetes centers or other facilities that bill on an institutional claim form (UB-92 or UB-04), can bill 95250 under their facility’s billing number.

Although CDEs may have a provider number and perform services associated with 95250 and medical nutritional therapy (MNT) or diabetes self-management education (DSMT), Medicare and most private payors do not recognize a CDE as a provider for the purpose of billing CPT code

95250. If a CDE is employed by an outpatient diabetes center, 95250 would be billed under the diabetes center’s provider number on a UB-92 or UB-04 claim form.

For a sample CMS-1500 and UB-04 claim forms for Professional CGM see Appendix form

Example R02 and R03.

PRACTICE GUIDE

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DM, TYPE I, controlled (see #1 - 3) 250.01

DM, TYPE I, uncontrolled (see #1 - 3) 250.03

DM, TYPE II, controlled (see #1 - 3)

DM, TYPE II, uncontrolled (see #1 - 3)

250.00

250.02

733.00

PATIENT AGE _______________

(If female & > 65 yrs, see #4)

Osteoporosis (See #4-7)

Pregnancy with Diabetes (See #1-3) 648.0*

Pregnancy w/Gest DM (See #1-3) 648.8*

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REIMBURSEMENT

CPT CODE 95251

Who can perform or bill CPT code 95251?

CPT code 95251 is for the interpretation of CGM data and does not need to be performed

face-to-face with the patient. Only a qualified physician or mid-level practitioner can perform the services associated with CPT 95251. If billed under a mid-level practitioner, payment may be slightly lower than for a physician. Although RDs are mid-level practitioners, many payors will not consider a RD for payment for 95251. This varies by state according to state scope of practice laws and by payor. Also, CPT 95251 should not be billed under a diabetes center provider number.

Analysis and interpretation should be clearly documented in the patient’s chart. In addition, it is useful to print professional CGM reports and include them in the patient’s medical record.

The exhibit below provides a summary of who can bill and perform Professional CGM services.

BILLS

BOTH on 1500 and UB Claim Form or

ONLY on1500 Claim Form

CAN BILL 95250

CAN BILL 95251

PRACTICE

95250

Can be Performed by Any

Qualified Health Care Provider

*:

• Physician

• CDE

• Mid-level

Practitioner

• MA

• Nurse

*Consistent with state scope of practice laws

95251

Should be Performed by a Physician or Mid-level Practitioner

Other Practice Staff can Provide Support,

Consistent with “incident to” Guidelines

BILLS

ONLY on

UB Claim Form

CAN BILL 95250

CANNOT BILL 95251

TIP:

If you don’t know whether you bill on a CMS -1500 or UB claim form, check with your billing department. Or, pull old claim forms and look at the number at the top of the claim form. If your practice uses a third-party billing service, you can ask your billing service which claims form(s) are used.

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PRACTICE GUIDE

DM, TYPE I, controlled (see #1 - 3) 250.01

DM, TYPE I, uncontrolled (see #1 - 3) 250.03

DM, TYPE II, controlled (see #1 - 3)

DM, TYPE II, uncontrolled (see #1 - 3)

250.00

250.02

733.00

PATIENT AGE _______________

(If female & > 65 yrs, see #4)

Osteoporosis (See #4-7)

Pregnancy with Diabetes (See #1-3) 648.0*

Pregnancy w/Gest DM (See #1-3) 648.8*

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REIMBURSEMENT

EVALUATION AND MANAGEMENT (E/M) CODES:

E/M codes are used for billing face-to-face, non-procedural services. The appropriate level of the E/M code you bill is based on multiple components of time and complexity. The components include history and physical examination, medical decision making, counseling, coordination of care, nature of presenting problem and time. Pursuant to available guidelines, when counseling and/or coordination of care constitute over 50 percent of an encounter, time may be considered the key factor in determining the level of E/M code.

The levels of E/M codes for established patients and the time associated with each are as follows

(there is a comparable series of E/M codes for new patients):

Code

99211

Ti m e

min

All of these codes, except for 99211, must be performed under the direct supervision of a physician (or

mid-level practitioner). Only 99211, the lowest level E/M code, can be performed by a nurse, or other non-physician or non-mid-level practitioner provider.

MODIFIERS:

If you perform evaluation and management services on the same day as services for 95250 and

95251, modifier -25 should be added to the E/M code.

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The explanation of modifier 25 from the

AMA CPT book is “Significant, Separately Identifiable Evaluation and Management Service by the

Same Physician on the Same Day of the Procedure or Other Service”. CPT codes 95250 or 95251 can be billed on the same day as an E/M code, as long as the E/M services are identifiable, separate, and above and beyond the services provided under code 95250 or 95251. For example, you can bill CPT code 9921x-25 if the physician performed a physical on the same day as an

iPro™ data download (x denotes level of E/M service). Documentation in the patient’s medical record must clearly demonstrate that a separate E/M service was medically necessary.

Note: Please refer to the “Frequently Asked Questions” found in the Appendix for additional details on coding.

DIAGNOSIS CODES:

ICD-9 diagnosis codes define why a service or procedure was performed and the appropriate diagnosis code(s) must be indicated on health care claims. Including the correct ICD-9 code(s) on claims is important, because payors use ICD-9 codes to determine whether the

billed service(s) is medically necessary, and thus is eligible for reimbursement.

Providers should always bill the most specific ICD-9 code possible, specifying a five-digit ICD-9 code whenever possible. If a patient has more than one condition, the healthcare provider should document all conditions in the patient’s medical record and include all of the relevant ICD-9 diagnosis codes on the claim form.

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When an E/M service is billed by the same provider on the same date of service, the -25 modifier must be used. This modifier is not specific to CGM services.

PRACTICE GUIDE

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DM, TYPE I, controlled (see #1 - 3) 250.01

DM, TYPE I, uncontrolled (see #1 - 3) 250.03

DM, TYPE II, controlled (see #1 - 3)

DM, TYPE II, uncontrolled (see #1 - 3)

250.00

250.02

733.00

PATIENT AGE _______________

(If female & > 65 yrs, see #4)

Osteoporosis (See #4-7)

Pregnancy with Diabetes (See #1-3) 648.0*

Pregnancy w/Gest DM (See #1-3) 648.8*

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REIMBURSEMENT

For CGM, the ICD-9 diagnosis codes for diabetes are typically billed. Effective October 1, 2008, twenty (20) new diagnosis codes were released to track secondary diabetes, defined as a diabetic condition whose underlying cause is not genetic or environmental conditions.

The following are examples of diabetes ICD-9 codes that are frequently used for CGM:

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Type of

Diabetes

ICD-9 Codes

Type I

Controlled

250.01

Type II

Controlled

250.00

Type I

Uncontrolled

250.03

Type II

Uncontrolled

250.02

Make sure that CGM billing codes, modifiers, and ICD-9 diagnosis codes are included on the

charge ticket (clinic superbill), whether your practice uses a paper-based or automated charge capture process (electronic medical records). Below is an example of a superbill with the relevant codes included.

Craniopharyngioma

Cushing’s Syndrome

Diabetes Insipidus

237.0

255.0

253.5

_99244 Comp Hx/Exam-Mod MDM

_99245 Comp Hx/Exam-High MDM

_99354 Prolonged service 30-74 min (face to face)

NEW PATIENT VISITS - SELF REFERRED FEE

_99201 Problem Focused Hx/Exam-SF MDM

_99202 Expanded Prob Foc Hx/Exam-SF MDM

_99203 Detailed Hx/Exam-Low MDM

_99204 Comp Hx/Exam-High MDM

_99205 Comp Hx/Exam-High MDM

Complications

________________

__ CREDIT CARD ___________

AMT PAID $

___________

FOLLOWUP INFORMATION

REFERRED TO:

________________

_1600363 IGD New pt visit**MEDICAID PTS ONLY Goiter, simple 240.0

_____________________________

_99354 Prolonged service 30-74 min (face to face)

ESTABLISHED PATIENT VISITS FEE

_99211 Presenting Problem Minimal

_99212 Problem Exposed Hx/Exam-SF MDM

_99214 Detailed Hx/Exam-Mod MDM

_99215 Comp Hx/Exam-High MDM

EXAMPLE

_1600364 IGD Established pt visit**MEDICAID PTS ONLY**

Graves Disease/Hyperthyroidism

Growth Hormone Deficiency

Hashimoto’s Thyroiditis

Hypocalcemia

242.0

253.5

245.2

275.41

250.8

Hypogonadism (female) 256.39

Hypogonadism (male) 257.2

Hypogonadism 253.4

SCHEDULE PT FOR:

DEXA SCAN ________________

X-RAY ________________

OTHER ________________

_99354 Prolonged service 30-74 min (face to face)

DIABETES EDUCATION FEE

_G0108 Indiviual Training

_97802 MNT, Initial Assess/Intervention

_97803 MNT, Re-assess/Intervention

_97804 MNT, Group

_95250 Glucose Sensor Monitoring

_95251 Ambulatory cont glucose monitor/int & rep

MISCELLANEOUS

_Mod 25 - to be Used for Separate & Significant E & M

Done w/procedure

_Visit based on time, total mins=____

(>50%counseling/documented)

PROCEDURES

_82962 Glucose fingerstick

FEE

_80061 Lipid Panel

_84460 ALT

_83036 AIC

_81002 Urinalysis w/o microscopy

_90658 Influenza Vaccine

_90471 Immunization Administration. 1st

_G0008 Immunization Administration (Medicare)

_5101740 Ibandronate Sodium. 1mg

_90772 Injection (indicate below)

_____ Practice Meds _____Patient Meds

Hypokalemia 276.8

Hypoparathyroidism, juvenile 252.1

Hypopituitarism 253.2

Hypothyroidism, primary 244.9

Hypothyroidism, due to antithyroid agents 244.2/E932.8

Hypothyroidism, post surgical 244.0

Irregular menses 626.4

Kallman’s Syndrome 253.4

Klinefelter’s Syndrome 758.7

Men I or II 237.4

Multinodular Goiter, nontoxic 241.1

Multinodular Goiter, nontoxic

(needs 5th digit)

242.2*

0=w/o mention of thryotoxic crisis, 1=w/mention of thryotoxic crisis

Obesity 278.00

Pheochromocytoma

Pituitary adenoma

227.0

227.3

Polyeystic ovaries 256.4

Pre-Diabetes/impaired fasting glucose 790.22

(needs 5th digit - use as primary dx)

(needs 5th digit - use as primary dx)

NEXT APPT:

________________________________

OTHER INSTRUCTIONS

PHYSICIAN SIGNATURE

_____________________________

FELLOW SIGNATURE

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These are examples only and are not comprehensive. The appropriate code for an individual patient will vary, and providers should always select the most relevant code or codes based on characteristics of the patient and the services provided.

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PRACTICE GUIDE

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DM, TYPE I, controlled (see #1 - 3) 250.01

DM, TYPE I, uncontrolled (see #1 - 3) 250.03

DM, TYPE II, controlled (see #1 - 3)

DM, TYPE II, uncontrolled (see #1 - 3)

250.00

250.02

733.00

PATIENT AGE _______________

(If female & > 65 yrs, see #4)

Osteoporosis (See #4-7)

Pregnancy with Diabetes (See #1-3) 648.0*

Pregnancy w/Gest DM (See #1-3) 648.8*

REIMBURSEMENT

OFFICE PROTOCOL AND REIMBURSEMENT

The chart below summarizes the key process steps for

iPro™ Professional CGM and the reimbursement information.

Patient Selection

HCP Prescribes

iPro

™

CGM

Verify

Insurance

Benefits

Schedule Visit

iPro CGM Start-Up:

Sensor Hook up,

Begin Evaluation

• Insert glucose sensor

• Educate p atient

• Connect

iPro

Recorder to sensor

• Provide patient with log sheet

Patient while at home:

• Takes 4 BG tests

each day

• Uses log sheet record daily activities

Data Download

Evaluation Complete

HCP Interprets

Report

• Remove

iPro

Recorder and sensor

• Download

iPro CGM and BG meter data

• Generate reports

400

300

200

150

100

70

0

HCP Makes

Recommendations to Patients During

Office Visits

CPT code 99211 - 99215

• If patient selection for

iPro CGM is done during a routine office visit, bill the appropriate E/M codes based on time and complexity

CPT code 95250

• Performed by physician or mid-level practitioner or by RN,

CDE, MA, lab tech, or RD with physician or mid-level practitioner supervision

• Bill AFTER reports are generated

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Add “-25” to E/M code if 95250 is billed for services completed on the same day E/M is billed for separate office visit

CPT code 95251

• Performed by physician or mid- level practitioner

• With or without patient in office

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Add “-25” to E/M code if 95251 is billed for services completed on the same day E/M is billed for separate office visit

CPT code 99211 - 99215

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Bill usual E/M codes based on time and/or content

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Add modifier “-25” to E/M code if 95250 and/or 95251 is billed for services completed on the same day E/M is billed for separate office visit

Pre-

iPro Professional CGM Evaluation

Patients will likely visit your office before being prescribed continuous glucose monitoring as part of their individual quarterly regular visit. If so, there will most likely be a face-to-face visit with the patient and an evaluation and management (E/M) code may be appropriate.

iPro CGM Evaluation (iPro CGM Startup and Data Download)

CPT code 95250 covers the services to insert the sensor on the patient, connect the

iPro Recorder to the sensor, give instructions to the patient, remove the sensor and

iPro Recorder after the evaluation, and download the data. Any qualified healthcare provider (consistent with state licensing requirements) can perform this step. CDEs employed by a diabetes center can perform this procedure and bill under a Diabetes Center provider number. Typically, CPT code 95250 should be billed after downloading the data from the

iPro Recorder, usually after the patient has returned the

iPro Recorder to your office.

PRACTICE GUIDE

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REIMBURSEMENT

Interpreting

iPro™ CGM Reports

CPT code 95251 is for analysis and interpreting the data in the

iPro reports. This analysis does not need to be performed face-to-face with the patient. Only an interpretation performed by a physician or a mid-level practitioner such as nurse practitioner (NP) or physician assistant (PA) can be billed under CPT code 95251.

Post

iPro CGM evaluation (therapy recommendations):

Therapy change involves making the clinical decisions and therapy adjustments utilizing the data revealed from the Professional CGM evaluation. This is usually conducted in a face-toface visit with the patient to share the results of the evaluation and discuss therapy options.

Bill this visit with the appropriate E/M code based on complexity of the visit and time spent with the patient.

COVERAGE:

Coverage policies describe which products and services are eligible for payment. Most payors, government and commercial, cover only services that are medically necessary and are not considered experimental or investigational. Payors institute specific coverage policies to ensure appropriate utilization and to control costs.

PRIVATE PAYOR COVERAGE OF PROFESSIONAL CGM

As of mid-2009, the majority of commercial plans have coverage for professional CGM. For example, United Healthcare, Cigna, Humana, Anthem WellPoint and most other Blue Cross/Blue

Shield plans have written policies.

For Professional CGM, many private payors have prior authorization requirements. For additional details on the Prior Authorization and Coverage process, please see the Appendix. Prior authorization for CGM may involve a phone call or submission of written documentation to the health plan before the Professional CGM service can be provided to the patient. Use a prior

authorization form (see Appendix form R04) and/ or a prior authorization tracker to track the status

(see Appendix form R06). Once approval is obtained, the appointment is then scheduled.

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PRACTICE GUIDE

DM, TYPE I, controlled (see #1 - 3) 250.01

DM, TYPE I, uncontrolled (see #1 - 3) 250.03

DM, TYPE II, controlled (see #1 - 3)

DM, TYPE II, uncontrolled (see #1 - 3)

250.00

250.02

733.00

PATIENT AGE _______________

(If female & > 65 yrs, see #4)

Osteoporosis (See #4-7)

Pregnancy with Diabetes (See #1-3) 648.0*

Pregnancy w/Gest DM (See #1-3) 648.8*

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REIMBURSEMENT

(Sample Only)

Most private payors cover Professional CGM for specific patient populations, often based on type of diabetes and level of control. It is important to understand the specific coverage

criteria for payors in your area, as each plan may have different criteria for patient selection and billing.

You might want to compile a coverage policy summary table that summarizes relevant coverage

information from your top payors (see Appendix form R07). This can become a handy reference in verifying medical benefits for individual patients. It is a good practice to update coverage information at least quarterly to make sure it reflects any policy changes.

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The table below is an example of a more detailed coverage policy summary table which includes preauthorization requirements and patient selection criteria. (see Appendix form R07)

(Sample Only)

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Payors update coverage decisions on an ongoing basis, so it is important that you routinely check for changes to coverage decisions and/or payor contracts.

PRACTICE GUIDE

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DM, TYPE I, controlled (see #1 - 3) 250.01

DM, TYPE I, uncontrolled (see #1 - 3) 250.03

DM, TYPE II, controlled (see #1 - 3)

DM, TYPE II, uncontrolled (see #1 - 3)

250.00

250.02

733.00

PATIENT AGE _______________

(If female & > 65 yrs, see #4)

Osteoporosis (See #4-7)

Pregnancy with Diabetes (See #1-3) 648.0*

Pregnancy w/Gest DM (See #1-3) 648.8*

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REIMBURSEMENT

MEDICARE COVERAGE OF PROFESSIONAL CGM

The Centers for Medicare and Medicaid Services (CMS), the federal government agency that administers the Medicare program, has not established a national coverage policy for Professional

CGM. This means that coverage is determined by each of the local contractors who process Medicare claims. Currently, Professional CGM under CPT codes 95250 and 95251 is payable by Medicare in all 50 states. Only one local coverage policy, which affects the state of Virginia, is currently active for Professional CGM.

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Local policies change frequently, especially as Medicare transitions to a new format for its local contractors. Therefore, you should always check your local Medicare

contractor’s website to determine the most current policy in place for Professional CGM. The websites for the current Medicare contractors are provided in form R01 (see Appendix).

Your local Medtronic Diabetes representative can also provide Medicare and commercial payor coverage information specific to your diabetes practice.

CLAIMS DENIALS AND APPEALS

Claims denials occur when the payor rejects the claim submitted by a provider. Claims denials can occur for a wide variety of reasons. It is important to understand why the claim was denied and what options are available to re-submit or appeal the claim, as appropriate.

BEST PRACTICES to address possible denials:

If you received a denial for

iPro™ Professional CGM services (based on use of the iPro CGM), the following checklist (pg 11) may help you understand the reason for denial.

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This policy was established by Trailblazers, the outgoing Medicare contractor for the state of Virginia. The policy specifies that Professional CGM is “intended to supplement self-monitoring data on a one-time or occasional basis. The occasion would be necessitated by poor diabetic control or recurrent hypoglycemia with or without neuroglycopenia. It is anticipated that patients will have proven refractory despite two months of intensive self-monitoring (i.e., 4 x per day self-monitoring via finger stick technique).” The Virginia contract was awarded to a new contractor in January 2009, and the new contractor is not obligated to maintain the existing policy once the transition is complete.

Source: http://www.trailblazerhealth.com/Tools/Local%20Coverage%20Determinations/Default.aspx?id=3161&DomainID=1

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PRACTICE GUIDE

DM, TYPE I, controlled (see #1 - 3) 250.01

DM, TYPE I, uncontrolled (see #1 - 3) 250.03

DM, TYPE II, controlled (see #1 - 3)

DM, TYPE II, uncontrolled (see #1 - 3)

250.00

250.02

733.00

PATIENT AGE _______________

(If female & > 65 yrs, see #4)

Osteoporosis (See #4-7)

Pregnancy with Diabetes (See #1-3) 648.0*

Pregnancy w/Gest DM (See #1-3) 648.8*

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REIMBURSEMENT

POSSIBLE REASONS

Do not understand the denials. No reason given or reason undecipherable

Payor may not have a formal policy for

Professional CGM

Health insurer may require prior-authorization

Patient does not meet criteria established by payor

POSSIBLE ACTION

Contact payor to obtain clarifications:

• Obtain details about why the claim denied

(which may not be clear from the claim denial)

• Learn the appeal options available and timing

and documentation requirements

• Verify that the claim was complete

• Verify that the correct date(s) of service and

provider number were included on the claim

File an appeal clearly delineating the reason that

Professional CGM is medically necessary for the patient.

See Appendix form R09 for a sample letter of medical necessity

Verify which payors in your area require pre-authorization, and always check if it is needed before providing the service

Confirm that diagnosis codes are appropriate.

Ensure that frequency of submissions are within policy limits (e.g., >1 / year). Always verify that a patient meets the payor’s coverage criteria before performing the service

Submit required supporting documentation, including the

Professional CGM tracing, with an appeal letter to validate the need for the service

Payor determines that the service is not medically necessary for the diagnosis (es) submitted

Frequency of submissions could be beyond policy limits (e.g., no greater than

2 times/ year)

E/M code was provided on the same day as 95250 and/or 95251

ICD-9 diagnosis code could flag the procedure as non-covered. Codes

250.00 and 250.01 without complications may be denied

Always verify frequency limits before performing the service. If claims are denied due to frequency, you can still submit an appeal letter to demonstrate the medical necessity of the additional service

Modifier -25 should be added to E/M if billed on same day as 95250/95251 (-25 verifies that the E/M code is a separate and identifiable service)

Verify appropriate ICD-9 diagnosis code with highest level of specificity was billed

PAYMENT:

Payment for services may differ by place of service and type of provider. If CPT code 95250 or 95251 is billed from a “physician office” as the place of service , it is typically paid under the physician fee schedule. A fee schedule assigns a specific payment amount to each CPT code. Medicare and most private payors use fee schedules to pay for physician services.

However, some payors may pay physicians based on billed charges or on a capitated basis.

If 95250 is billed by a hospital-based outpatient diabetes center, the facility will be reimbursed under the payor’s outpatient hospital payment system. Payors use a variety of mechanisms for reimbursing hospital outpatient services. Medicare and some private payors pay for hospital outpatient services based on Ambulatory Payment Classifications (APCs), which assign services to payment categories. Other private payors pay for hospital outpatient services based on billed charges or according to fee schedules.

PRACTICE GUIDE

11

DM, TYPE I, controlled (see #1 - 3) 250.01

DM, TYPE I, uncontrolled (see #1 - 3) 250.03

DM, TYPE II, controlled (see #1 - 3)

DM, TYPE II, uncontrolled (see #1 - 3)

250.00

250.02

733.00

PATIENT AGE _______________

(If female & > 65 yrs, see #4)

Osteoporosis (See #4-7)

Pregnancy with Diabetes (See #1-3) 648.0*

Pregnancy w/Gest DM (See #1-3) 648.8*

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•

REIMBURSEMENT

The 2009 Medicare national average physician and hospital outpatient payment amounts for

95250 and 95251 are provided below, along with an estimate of private payor payment based on 1.5 times the 2009 Medicare National Average Allowable rates. The Medicare information provided is the National Average Allowable; actual rates will vary by geography. The Medicare allowable amounts include the patient co-insurance amount.

2009 CONTINUOUS GLUCOSE MONITORING FEE SCHEDULE/ REIMBURSEMENT

Medicare

Description

RVU

8

Medicare

9

Physician

Fee Schedule

Medicare

10

,

11

Hospital

Outpatient

Prospective

Payment

System

Private Payor

7

Physician

Reimbursement

95250

Ambulatory continuous glucose monitoring of interstitial 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 report more than once per month]

3.56

$128 $106

(APC 0607)

$193

95251

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

[Do not report more than once per month]

1.10

$40 Paid under physician fee schedule

$60

Evaluation and Management (E/M) Codes:

99212 Established Patient Visit

99213 Established Patient Visit

99214 Established Patient Visit

99215 Established Patient Visit

1.03

1.70

2.56

3.46

$37

$61

$92

$125

$23

$45

$69

$98

$56

$92

$138

$187

7

Private payor rates are estimated at 1.5 times the 2009 Medicare National Average Allowable rates (rounded to the nearest dollar). These rates are for illustrative purposes only, as private payor rates vary widely.

8

CMS 2009 Medicare Physician Fee Schedule, Addendum B.

9

CMS 2009 Medicare Physician Fee Schedule, Addendum B. The number provided is the Medicare National Average

Allowable, which is not geographically adjusted and includes the patient deductible and coinsurance.

10

CMS 2009 Hospital Outpatient Prospective Payment System, Addendum B The number provided is the Medicare

National Average Allowable, which is not geographically adjusted and includes the patient deductible and coinsurance.

11

Many Outpatient Diabetes Centers fall in this category.

12

PRACTICE GUIDE

DM, TYPE I, controlled (see #1 - 3) 250.01

DM, TYPE I, uncontrolled (see #1 - 3) 250.03

DM, TYPE II, controlled (see #1 - 3)

DM, TYPE II, uncontrolled (see #1 - 3)

250.00

250.02

733.00

PATIENT AGE _______________

(If female & > 65 yrs, see #4)

Osteoporosis (See #4-7)

Pregnancy with Diabetes (See #1-3) 648.0*

Pregnancy w/Gest DM (See #1-3) 648.8*

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REIMBURSEMENT

BEST PRACTICES to monitor Professional CGM reimbursement :

Many offices find it useful to collect explanations of benefits (EOBs), which are provided by the payor for each claim processed. Many offices find it beneficial to analyze reimbursement rates and levels.

Some practices run quarterly Professional CGM payment collection summary reports (see Appendixx

form R05) that show the utilization of their Professional CGM recorders by office staff and actual payments they received. Utilization data helps the practice to understand future requirements for staffing, space and equipment for Professional CGM services. Annually, a table is generated with net payment received for each Professional CGM evaluation. The data is obtained from the EOB received for each case. The table helps the office understand the average payment they receive for CGM as well as payment levels from each payor. Please see below for an example of the Payment collection summary report. (see Appendix form R05)

DM, TYPE I, controlled (see #1 - 3) 250.01

DM, TYPE I, uncontrolled (see #1 - 3) 250.03

DM, TYPE II, controlled (see #1 - 3)

DM, TYPE II, uncontrolled (see #1 - 3)

250.00

250.02

733.00

PATIENT AGE _______________

(If female & > 65 yrs, see #4)

Osteoporosis (See #4-7)

Pregnancy with Diabetes (See #1-3) 648.0*

Pregnancy w/Gest DM (See #1-3) 648.8*

•

•

•

•

•

•

•

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•

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•

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•

PRACTICE GUIDE

13

DM, TYPE I, controlled (see #1 - 3) 250.01

DM, TYPE I, uncontrolled (see #1 - 3) 250.03

DM, TYPE II, controlled (see #1 - 3)

DM, TYPE II, uncontrolled (see #1 - 3)

250.00

250.02

733.00

PATIENT AGE _______________

(If female & > 65 yrs, see #4)

Osteoporosis (See #4-7)

Pregnancy with Diabetes (See #1-3) 648.0*

Pregnancy w/Gest DM (See #1-3) 648.8*

REIMBURSEMENT

Some offices also compare the average payment for Professional CGM procedures as compared to other procedures. An example of the Payment Collection Summary template to use is listed below (see Appendix form R08). It is noted that the average payment and collection rates for CPT code 95250 are very competitive as compared with other diabetes services.

(FORM R08)

(FORM R05)

BEST PRACTICES:

What if the reimbursement amount is lower than expected?

√

Recognize your responsibility for negotiating your practice’s procedural reimbursement rates with the health insurers.

√

Contact the insurance provider to confirm your contracted reimbursement rates for CPT codes 95250 and 95251.

√

Work with your insurance provider to explain the importance of

Professional CGM in your practice.

√

Office may have to wait until contract renewal to negotiate terms.

Make sure office manager and physicians put 95250/95251 on their list of “must negotiate” items to the next contract.

14

PRACTICE GUIDE

•

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•

DM, TYPE I, controlled (see #1 - 3) 250.01

DM, TYPE I, uncontrolled (see #1 - 3) 250.03

DM, TYPE II, controlled (see #1 - 3)

DM, TYPE II, uncontrolled (see #1 - 3)

250.00

250.02

733.00

PATIENT AGE _______________

(If female & > 65 yrs, see #4)

Osteoporosis (See #4-7)

Pregnancy with Diabetes (See #1-3) 648.0*

Pregnancy w/Gest DM (See #1-3) 648.8*

•

•

•

•

•

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•

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•

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•

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•

•

APPENDIX

REIMBURSEMENT

Prior Authorization Process

Keys to Success in Gaining Prior Authorization

The keys to successful prior authorization and appropriate reimbursement from a payor include:

1. Identify a staff member within your practice to coordinate prior authorization and

pre-certification processes with third-party payors

2. Involve the patient and/or family in the prior authorization

process as appropriate

3. Follow the payor’s conditions for coverage. They vary and are very specific.

4. Prepare a clear and concise letter of medical necessity (if necessary)

5. Educate the payor regarding CGM, as needed

Verbal authorization may be given based on the above information. Written authorization is preferred. Whether authorization is verbal or written, obtain an authorization number.

For written authorization, you will need to provide:

• Letter of medical necessity (see Appendix sample letter R09)

• Patient records or provide narrative of patient’s history

PRACTICE GUIDE

15

APPENDIX

REIMBURSEMENT

Steps in the Prior Authorization (PA) Process

PROFESSIONAL CGM COVERAGE PROCESS

IDENTIFY PATIENT FOR CGM

IDENTIFY PAYOR AND COVERAGE

CONTACT PAYOR - DETERMINE IF

PRIOR AUTHORIZATION IS REQUIRED

COVERED?

NO

Reverify

Eligibility

PROVIDE SERVICE

Submit Claim for

Payment

YES, WITH WRITTEN POLICY

Understand Prior

Authorization Requirement

PA NEEDED?

YES

UNCERTAIN, NO WRITTEN POLICY

Case by Case

Request for Approval

{LMN, clinical data, BG log, complication, ER visit}

Collect & Submit Documentation

{LMN, clinical data, BG log, complication, ER visit}

Collect & Submit

PA Documentation

{LMN, clinical data, BG log, complication, ER visit}

PA Approved

NO

APPROVED?

Denied

APPEAL

Submit Letter of Appeal

Contact Payor Ask for Phone

Consult with Medical Director

YES

PROVIDE SERVICE

Submit Claim for

Payment

NO, HAVE WRITTEN

NON-COVERAGE POLICY

Request Procedure with Documentation of Medical Necessity

Step 1:

Contact Payor (this should be done initially with each payor until the PA process is established)

• Inquire about eligibility

• Understand if the plan has a coverage policy for CGM. Before proceeding with the

case-by-case coverage process, it is important to verify if the payor has a coverage

• Determine if prior authorization is needed

• Determine payor requirements for prior authorization

16

PRACTICE GUIDE

DM, TYPE I, controlled (see #1 - 3) 250.01

DM, TYPE I, uncontrolled (see #1 - 3) 250.03

DM, TYPE II, controlled (see #1 - 3)

DM, TYPE II, uncontrolled (see #1 - 3)

250.00

250.02

733.00

PATIENT AGE _______________

(If female & > 65 yrs, see #4)

Osteoporosis (See #4-7)

Pregnancy with Diabetes (See #1-3) 648.0*

Pregnancy w/Gest DM (See #1-3) 648.8*

•

•

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APPENDIX

REIMBURSEMENT

Step 2:

Collect information

• Collect all patient, payor and physician information

• Identify all ICD-9 diagnoses and CPT codes

• Letter of medical necessity (see Appendix sample letter R09)

• Patient records (information about the patient’s history may be included in your letter).

Step 3:

Submit Requested and Other Supporting Information

• Gather all requested materials and mail or fax them to the individual or department responsible for the payor’s prior authorization decisions.

• Include a letter of medical necessity for continuous glucose monitor (CGM), which may include:

- Documented glycemic control problems (elevated A1c, frequent hypoglycemia,

- Hospitalizations for hypoglycemia or Diabetic ketoacidosis (DKA)

- Emergency room visits

- Glucagon administrations

- Diabetes complications, whether early or advanced, such as kidney problems , nerve

damage, loss of feeling in feet, and eye problems

• Description of the patient’s treatment plan (e.g. multiple daily injections or insulin pump, and frequency of self monitoring of blood glucose) and a record of adherence to the patient’s care plan.

• Cite the Aetna, CIGNA, Humana, United Healthcare, and WellPoint/Anthem policies covering CGM

• Cite current clinical studies which show CGM improve glycemic control

• Key to success: Continue to follow-up routinely with the payor until a coverage decision has been made.

Step 4:

Re-verify Eligibility

• When prior authorization has been granted, you may want to re-verify the patient’s eligibility to ensure that the patient is still covered by this payor

Step 5:

Appeal (if prior authorization is denied)

• Understand the reason for the denial

• Understand the process for filing an appeal

• Document if your state has a diabetes mandate that may impact coverage for CGM

• Submit your appeal. Send the appeal to the insurance plan within the timeframe outlined by your insurer

• Be prepared and persistent. Seeking case-by-case coverage requires persistence. Make sure to be prepared and keep trying!

• If iPro™ CGM evaluation was completed, you might consider submitting the CGM tracings with the appeal and an explanation of the clinical value of the study and how the patient benefited from the evaluation.

A sample letter of appeal (see Appendix form R10) is provided for your reference only. Please utilize this letter as you see fit in your practice, by revising / supplementing it for your actual cases.

PRACTICE GUIDE

17

DM, TYPE I, controlled (see #1 - 3) 250.01

DM, TYPE I, uncontrolled (see #1 - 3) 250.03

DM, TYPE II, controlled (see #1 - 3)

DM, TYPE II, uncontrolled (see #1 - 3)

250.00

250.02

733.00

PATIENT AGE _______________

(If female & > 65 yrs, see #4)

Osteoporosis (See #4-7)

Pregnancy with Diabetes (See #1-3) 648.0*

Pregnancy w/Gest DM (See #1-3) 648.8*

•

•

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•

APPENDIX

REIMBURSEMENT

Frequently Asked Questions

1.

Can you bill an E/M code on the same day as CPT 95250 and/or 95251?

Yes, both CPT 95250 and CPT 95251 can be billed on the same day as an E/M code, so long as a distinct and separate E/M service was provided. When an E/M code is billed by the same provider on the same day as another service, including CPT 95250 or 95251, the modifier -25 must be attached to the E/M code. The definition of the -25 modifier is, "significant, separately identifiable evaluation and management (E/M) service by the same physician on the day of a procedure." Be sure to clearly document both the

iPro™ services and the separate E/M services that were provided in the patient's medical record.

2.

How frequently can

iPro CGM be performed?

iPro CGM should only be performed when the service is medically necessary. The AMA has clarified that CPT codes 95250 and 95251 should not be billed more than once per month per patient.

However, payors are not obligated to cover

iPro once per month. Payors can determine their own frequency limits for

iPro, and payor policies vary. Always verify how frequently the patient's insurance plan covers

iPro prior to performing the service.

3. When should the 95250 be billed (at training/hook-up or at download)?

CPT code 95250 should be billed once all of the components of the code have been performed, including sensor placement, hook-up, calibration of monitor, patient training, removal of sensor, and download/printout of recording. Since the download and printout of the recording is the final step defined within the 95250 code descriptor, appropriate billing would be performed after you have downloaded the data.

4. Who can perform and bill for 95250 and 95251?

95250 can be performed by any qualified health care practitioner, including physicians, mid-level practitioners, and other staff such as RNs, CDEs, and MAs, consistent with state scope of practice laws. 95250 can be billed on a CMS-1500 claim form by a physician or a mid-level practitioner, who is contracted to bill with the plan in question. Diabetes Centers can bill for 95250 on a UB-04/UB-92 claim form.

95251 can only be performed and billed by a physician or qualified mid-level practitioner, such as an NP or PA. Diabetes Centers that bill on a UB-04/UB-92 claim form cannot bill for 95251. Note: 99091 should not be used for Professional CGM report interpretation as 95251 is more specific for this procedure.

18

PRACTICE GUIDE

DM, TYPE I, controlled (see #1 - 3) 250.01

DM, TYPE I, uncontrolled (see #1 - 3) 250.03

DM, TYPE II, controlled (see #1 - 3)

DM, TYPE II, uncontrolled (see #1 - 3)

250.00

250.02

733.00

PATIENT AGE _______________

(If female & > 65 yrs, see #4)

Osteoporosis (See #4-7)

Pregnancy with Diabetes (See #1-3) 648.0*

Pregnancy w/Gest DM (See #1-3) 648.8*

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APPENDIX - FORMS

REIMBURSEMENT

(Form Example R01) http://www.wpsmedicare.com/j5macpartb/

DM, TYPE I, controlled (see #1 - 3) 250.01

DM, TYPE I, uncontrolled (see #1 - 3) 250.03

DM, TYPE II, controlled (see #1 - 3)

DM, TYPE II, uncontrolled (see #1 - 3)

250.00

250.02

733.00

PATIENT AGE _______________

(If female & > 65 yrs, see #4)

Osteoporosis (See #4-7)

Pregnancy with Diabetes (See #1-3) 648.0*

Pregnancy w/Gest DM (See #1-3) 648.8*

•

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•

APPENDIX - FORMS

REIMBURSEMENT

(Form Example R02)

DM, TYPE I, controlled (see #1 - 3) 250.01

DM, TYPE I, uncontrolled (see #1 - 3) 250.03

DM, TYPE II, controlled (see #1 - 3)

DM, TYPE II, uncontrolled (see #1 - 3)

250.00

250.02

733.00

PATIENT AGE _______________

(If female & > 65 yrs, see #4)

Osteoporosis (See #4-7)

Pregnancy with Diabetes (See #1-3) 648.0*

Pregnancy w/Gest DM (See #1-3) 648.8*

•

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•

APPENDIX - FORMS

REIMBURSEMENT

(Form Example R03)

DM, TYPE I, controlled (see #1 - 3) 250.01

DM, TYPE I, uncontrolled (see #1 - 3) 250.03

DM, TYPE II, controlled (see #1 - 3)

DM, TYPE II, uncontrolled (see #1 - 3)

250.00

250.02

733.00

PATIENT AGE _______________

(If female & > 65 yrs, see #4)

Osteoporosis (See #4-7)

Pregnancy with Diabetes (See #1-3) 648.0*

Pregnancy w/Gest DM (See #1-3) 648.8*

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

DM, TYPE I, controlled (see #1 - 3) 250.01

DM, TYPE I, uncontrolled (see #1 - 3) 250.03

DM, TYPE II, controlled (see #1 - 3)

DM, TYPE II, uncontrolled (see #1 - 3)

250.00

250.02

733.00

PATIENT AGE _______________

(If female & > 65 yrs, see #4)

Osteoporosis (See #4-7)

Pregnancy with Diabetes (See #1-3) 648.0*

Pregnancy w/Gest DM (See #1-3) 648.8*

•

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•

APPENDIX - FORMS

REIMBURSEMENT

(Form R04)

DM, TYPE I, controlled (see #1 - 3) 250.01

DM, TYPE I, uncontrolled (see #1 - 3) 250.03

DM, TYPE II, controlled (see #1 - 3)

DM, TYPE II, uncontrolled (see #1 - 3)

250.00

250.02

733.00

PATIENT AGE _______________

(If female & > 65 yrs, see #4)

Osteoporosis (See #4-7)

Pregnancy with Diabetes (See #1-3) 648.0*

Pregnancy w/Gest DM (See #1-3) 648.8*

•

•

•

•

•

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•

APPENDIX - FORMS

REIMBURSEMENT

(Form R05)

APPENDIX - FORMS

REIMBURSEMENT

(Form R06)

DM, TYPE I, controlled (see #1 - 3) 250.01

DM, TYPE I, uncontrolled (see #1 - 3) 250.03

DM, TYPE II, controlled (see #1 - 3)

DM, TYPE II, uncontrolled (see #1 - 3)

250.00

250.02

733.00

PATIENT AGE _______________

(If female & > 65 yrs, see #4)

Osteoporosis (See #4-7)

Pregnancy with Diabetes (See #1-3) 648.0*

Pregnancy w/Gest DM (See #1-3) 648.8*

•

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•

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•

APPENDIX - FORMS

REIMBURSEMENT

(Form R07)

DM, TYPE I, controlled (see #1 - 3) 250.01

DM, TYPE I, uncontrolled (see #1 - 3) 250.03

DM, TYPE II, controlled (see #1 - 3)

DM, TYPE II, uncontrolled (see #1 - 3)

250.00

250.02

733.00

PATIENT AGE _______________

(If female & > 65 yrs, see #4)

Osteoporosis (See #4-7)

Pregnancy with Diabetes (See #1-3) 648.0*

Pregnancy w/Gest DM (See #1-3) 648.8*

•

•

•

•

•

•

•

•

•

•

•

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•

•

•

•

•

•

APPENDIX - FORMS

REIMBURSEMENT

(Form R08)

DM, TYPE I, controlled (see #1 - 3) 250.01

DM, TYPE I, uncontrolled (see #1 - 3) 250.03

DM, TYPE II, controlled (see #1 - 3)

DM, TYPE II, uncontrolled (see #1 - 3)

250.00

250.02

733.00

PATIENT AGE _______________

(If female & > 65 yrs, see #4)

Osteoporosis (See #4-7)

Pregnancy with Diabetes (See #1-3) 648.0*

Pregnancy w/Gest DM (See #1-3) 648.8*

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

APPENDIX - FORMS

REIMBURSEMENT

(Sample Letter R09)

DM, TYPE I, controlled (see #1 - 3) 250.01

DM, TYPE I, uncontrolled (see #1 - 3) 250.03

DM, TYPE II, controlled (see #1 - 3)

DM, TYPE II, uncontrolled (see #1 - 3)

250.00

250.02

733.00

PATIENT AGE _______________

(If female & > 65 yrs, see #4)

Osteoporosis (See #4-7)

Pregnancy with Diabetes (See #1-3) 648.0*

Pregnancy w/Gest DM (See #1-3) 648.8*

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

APPENDIX - FORMS

REIMBURSEMENT

(Sample Letter R10)

DM, TYPE I, controlled (see #1 - 3) 250.01

DM, TYPE I, uncontrolled (see #1 - 3) 250.03

DM, TYPE II, controlled (see #1 - 3)

DM, TYPE II, uncontrolled (see #1 - 3)

250.00

250.02

733.00

PATIENT AGE _______________

(If female & > 65 yrs, see #4)

Osteoporosis (See #4-7)

Pregnancy with Diabetes (See #1-3) 648.0*

Pregnancy w/Gest DM (See #1-3) 648.8*

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•