According to the Centers for Disease Control and Prevention, over 37 million Americans, including adults and children, have diabetes. If not managed properly, this chronic condition can lead to serious complications. Continuous glucose monitoring (CGM) is a reliable option to help patients manage their blood sugar levels and help keep diabetes in check. New codes for continuous glucose monitors (CGMs) came into effect on April 1, 2022. As they help patients manage their blood sugar levels, physicians and device suppliers can rely on medical billing outsourcing services for accurate reporting and billing.
Before discussing the new CGM codes and billing guidelines, let’s take a look at how CGM works and its benefits.
CGM Features and Benefits
CGM is an external device with a small sensor that is attached to the body to continuously measure glucose in the blood. Bloodless glucose monitoring systems also include noninvasive optical glucose monitoring, noninvasive fluid sampling, and minimally invasive devices (MI-GM). A professional CGM system is a clinic-owned device. Patients can also purchase a CGM system for their own use.
Unlike conventional glucose meters that use finger-sticks and provide a glucose measurement at a specific point of time, CGM provides people with type 1 or type 2 diabetes accurate, real-time glucose readings at 5- to 15-minute intervals. Bloodless glucose monitoring devices measure glucose levels continuously and send the data to a smartphone or a wireless handheld device specifically designed for CGM. The data can be downloaded and used for report preparation. The physician can then use the report for data interpretation and therapeutic decision making.
With CGM data, patients and their physicians can see data patterns that will allow them to better tailor diets, lifestyle, and medications to manage blood sugar levels. The key benefits of CGM include:
- Patients can share information from their personal CGM with their physician
- Promotes more personalized care
- Improves patient’s overall glycemic control
- Provides data on overnight blood sugar levels
- Better insights about blood sugar trends
- Alarms can be set for maximum detection of glucose thresholds for hypo/hyperglycemia
- Lowers risk of emergencies from low or high blood sugar
With continual technological advancements, tools, and methodologies, the use of CGM is growing. A MedTechDive report referenced research from Jefferies which found that while 30% of the U.S. Type 2 patients used the technology in 2021, this proportion could rise to 50% in the next three years. The study was based on Jefferies’ survey of about 50 endocrinologists and general practitioners. According to Jefferies, the forecast factors in 1.6 million U.S. Type 1 patients, 2.5 million U.S. Type 2 insulin intensive patients, and 6.8 million total worldwide Type 2 insulin intensive patients, based on data from sources including the American Diabetes Association, Centers for Disease Control and Prevention, JDRF, and private and public companies.
Reporting diabetes and CGM using the latest codes is critical for billing services correctly.
New CGM Codes and Billing Guidelines effective April 1, 2022
The Centers for Medicare & Medicaid Services (CMS) issued a final rule on durable medical equipment (DMEs) that took effect on February 28, 2022:
- The final rule classifies non-implantable CGMs as DME, regardless of whether the CGM has been approved or cleared by the Food and Drug Administration (FDA) to replace a blood glucose monitor for use in making diabetes treatment decisions.
- Adjunctive CGMs – Adjunctive CGMs that do not replace a blood glucose monitor are referred to as adjunctive CGMs because they can be used as an adjunct to the blood glucose monitor by showing trends in glucose levels and alerting the patient about potentially dangerous levels, even while they sleep, that then must be verified by use of a separate blood glucose monitor.
- Non-adjunctive CGMs – Non-adjunctive CGM receivers are DME that displays and monitors the continuous glucose readings and trends, and replace the use of a blood glucose monitor in diabetes treatment decision-making.
Monthly Supplies for Adjunctive CGMs
Invalid codes: Effective April 1, 2022, the following HCPCS codes are invalid for Medicare use for billing individual CGM supplies and accessories and not reflective of a monthly allowance.
- A9276 and A9277
New codes: Effective for claims with dates of service on or after April 1, 2022, suppliers should use the following new HCPCS codes to submit claims for the monthly supplies for adjunctive CGMs:
- E2102 Adjunctive continuous glucose monitor or receiver
- A4238 Supply allowance for non-implantable adjunctive continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service (for the monthly supplies for adjunctive CGMs)
Insulin pumps that can also be used as CGM receivers: CMS also announced special Instructions with regards to insulin pumps that can also be used as CGM receivers. For claims with dates of service on or after April 1, 2022, suppliers should use the HCPCS code and modifier combination of E2102 plus E0784 to bill for insulin pumps that also function as adjunctive CGM receivers.
- E0784 External ambulatory infusion pump, insulin
Note: CMS specifies that:
- These billing instructions do not apply if the beneficiary already owns a CGM receiver of any kind (adjunctive or non-adjunctive) and the receiver is less than five years old, or, if the beneficiary owns an insulin infusion pump that is less than five years old.
- The Level II HCPCS codes issued are intended to describe non-implantable CGMs that fall under the Medicare benefit for DME.
- Implantable CGMs do not fall under the Medicare benefit for DME and cannot be billed as such
More codes for CGM services and insulin delivery for managing diabetes are available at United Healthcare: https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/continuous-glucose-monitoring-insulin-delivery-managing-diabetes.pdf.
Professional CGM is payable by Medicare in all 50 states. Patients’ benefit coverage for CGM services would be determined by their specific benefit plan document and applicable laws that may require coverage for this service. As payers may require prior authorization for professional CGM used for the management of type 2 intensive insulin and gestational diabetes, insurance eligibility verification should be performed. Once prior authorization has been obtained, the physician can prepare the patient and implement the CGM program. An experienced endocrinology medical billing company can help medical practices report CGM services using the right billing codes, improve self-care outcomes and diabetes metrics, and generate a steady revenue stream.
Rajeev Rajagopal, the President of OSI, has a wealth of experience as a healthcare business consultant in the United States. He has a keen understanding of current medical billing and coding standards.