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FreeStyle Libre Pro system  //  Coverage & Reimbursement

Professional continuous glucose monitoring (CGM)

a reimbursable procedure with broad coverage for people with diabetes*

88% of commercial lives are members of a plan with written pro-CGM coverage

88%

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

100% of fee-for-service Medicare patients have pro-CGM coverage

100%

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

Professional CGM Workflow & Associated Billing Codes

Step
1

PRE-WORK

PATIENT SELECTION

HCP prescribes pro-CGM

Patient in office

VERIFY INSURANCE BENEFITS

(Submit prior authorization if required)

SCHEDULE VISIT

Step
2

PROCEDURE CPT
95250

  • Performed by physician or office staff under supervision, per state scope of practice

BEGIN ASSESSMENT

  • Insert 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
3

INTERPRETATION CPT
95251

  • Performed by physician or office staff under supervision, per state scope of practice

HCP INTERPRETS & REPORTS

With/without patient in office

Step
4

INFORMED
DECISION-MAKING

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.

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 schedule3,4
Medicare allowable

$159.69

Private payer5
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.

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

Access reimbursement support

Professional CGM Reimbursement Guide

Abbott Diabetes Care Reimbursement Customer Support

Call 877-549-9181
between 8 am-8 pm ET, Monday-Friday

Have a sales representative provide more information

*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 local Medicare administrative contractor.

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.

References: 1. Data on file. Analysis of Policy Reporter. 2. Physician fee schedule search. Centers for Medicare & Medicaid Services website. https://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx. Accessed October 16, 2018. 3. Determining Medicare Payments PPRRVU16_V0122.xlsx https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/ 4. January 2016 Web Addendum B.12.14.15.xlsx https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/ 5. 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.

ADC-05533 V2.0 11/19

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