DISCLAIMER: ECHO Nevada emphasizes patient privacy and asks participants to not share ANY Protected Health Information during ECHO clinics.

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1 DISCLAIMER: Video will be taken at this clinic and potentially used in Project ECHO promotional materials. By attending this clinic, you consent to have your photo taken and allow Project ECHO to use this photo and/or video. If you don t want your photo taken, please let us know. Thank you! ECHO Nevada emphasizes patient privacy and asks participants to not share ANY Protected Health Information during ECHO clinics.

2 CONTINUOUS GLUCOSE MONITORING PART 4 Veronica Brady, PhD, FNP- C, BC-ADM, CDE University of Nevada, Reno School of Medicine September 7, 2017

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4 COURSE OUTLINE (4-40 MINUTE SEGMENTS) 1. What is CGM professional personal 2. Identification of appropriate candidates for CGM pre-dm, T1 or T2DM patients not at goal hypoglycemia unawareness 3. Interpretation of data review downloads from 3 available devices 4. Billing and coding cost of professional device ROI billing codes

5 OBJECTIVES 1. Define continuous glucose monitoring (CGM) 2. Identify the different types of CGM devices 3. Identify appropriate candidates for the use of CGM 4. Verbalize understanding of data interpretation 5. Have a beginning knowledge of billing for CGM insertion and interpretation

6 BRIEF REVIEW

7 WHY USE CGM COST SAVINGS Direct costs for both Type 1 and Type 2 DM, episodes requiring assistance from a healthcare practitioner were $1161 per episode (direct costs) compared with episode costs of $66 and $11 for events requiring third-party (non-medical) assistance and events managed by self-treatment, respectively. Indirect costs associated with severe hypoglycemia requiring non-medical assistance, severe hypoglycemia requiring medical assistance, and non-severe hypoglycemia were predicted to be $242, $160, and $11 for patients with Type 1 diabetes and $579, $176, and $11 for patients with Type 2 diabetes, respectively. Foos, et al Tadej Battelino et al. Dia Care 2011;34:

8 PATIENT IDENTIFICATION AACE & ACE Consensus 2017 CGM is recommended for patients with type 1 diabetes who have a history of severe hypoglycemia, hypoglycemia unawareness, or frequent hyperglycemia. ADA Standards of Care 2017 Continuous glucose monitoring (CGM) in conjunction with intensive insulin regimens is a useful tool to lower A1C in selected adults (aged 25 years) with type 1 diabetes. CGM may be a useful tool in those with hypoglycemia unawareness and/or frequent hypoglycemic episodes.

9 CLINIC COST

10 PROFESSIONAL CGM COST Real-time Receiver - $ Transmitter- $ Sensors (4pk)- $ Blinded-Retrospective FreeStyle Libre Reader - $ Sensor (per) -- $ Medtronic Sof-sensor (4pk)- $ IPro2- $699-$ Cost of staff time-insertion, removal download, cleaning, obtaining prior authorizations Miscellaneous- cleaning supplies, batteries

11 BILLING FOR CGM

12 STEP 1--PRE-WORK INSURANCE REIMBURSEMENT Patient selection- verify insurance benefits Submit for prior authorization (if needed) If patient is self-pay they will need to pay for & Schedule Visit

13 STEP 2 Assessment-begin Insert sensor Educate patient Data Collection Must collect at least 72 hours of data in order to bill Assessment- complete Remove sensor Download data Generate reports

14 PROCEDURE CPT Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; Sensor placement, hook-up, calibration or monitor; patient training, removal of sensor and printout of recording (Do not repeat more that once a month) E/M can only be billed separately on the same day if a significant and separately identifiable service took place above and beyond CGM associated services. Modifier-25 is required if office visit billed on same day

15 STEP 3 Health care provider interprets and Reports This can be done with or without patient in office

16 INTERPRETATION CPT Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours: Separate visit from and billed separately MD, PA, NP only for review and interpretation If personal CGM you can bill at each visit (no more often than monthly). Interpretation does not need to be face to face Office visits on same day a require modifier -25 to be added to E/M coded (i.e with 95251)

17 REIMBURSEMENT Medicare CPT $ Commercial CPT $ CPT $ CPT $ 87.00

18 ISSUES

19 INCREASED CLINIC COST Be sure to have patients sign agreement that they will be responsible for cost of lost equipment. Set up plan to identify patients so that professional CGM is utilized as much as possible. Review denials on a routine basis. Ensure that all CPT have matching CPT for each patient.

20 DENIALS!! Not all payers cover Did you obtain prior authorization? Was it medically necessary? Submit CGM tracings and documentation if appeal needed Did you use proper ICD-10 codes? Use 5 digit code (E10.65, E11.65) Need to document uncontrolled DM Did you bill correctly? Bill and as separate visits Include modifier -25

21 TAKE HOME MESSAGE Identify patient population prior to purchasing CGM. Determine which system is right for your office. Be sure to obtain prior authorization, if needed. Ensure proper ICD-10 and CPT codes when billing.

22 MY CONTACTS FreeStyle Libre Jeff Staples (916) Dexcom Eddie Barrera (916) Medtronic Josh Quinn (818)

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