Final Continuous Glucose Monitor (CGM) Policy Released

Published in Home Medical Equipment on March 07, 2023

Final Continuous Glucose Monitor (CGM) Policy ReleasedThis article was originally written by The van Halem Group

Medicare released the final draft of the new Glucose Monitor LCD and Policy Article with an effective date of April 16, 2023. The change was completed after a response to comments for the LCD. This new policy revamps the current CGM coverage criteria with some highlights below.

Initial Coverage

The beneficiary for whom a CGM is being prescribed can be insulin treated or non-insulin treated with additional criteria.

  • The beneficiary is insulin-treated; or,
  • The beneficiary has a history of problematic hypoglycemia with documentation of at least one of the following:
    • Beneficiaries with non-insulin treated diabetes and a history of recurrent (more than one) level 2 hypoglycemic events.
  • The treating practitioner must document at least one of the following in the medical record for each event: 
    • The glucose values for the qualifying event(s) (glucose <54mg/dL (3.0mmol/L)); or,
    • Classification of the hypoglycemic episode(s) as level 2 event(s); or,
    • Incorporate a copy of the beneficiary’s BGM testing log into the medical record reflecting the specific qualifying events (glucose <54mg/dL (3.0mmol/L)); and,
    • Documentation of more than one previous medication adjustment and/or modification to the treatment plan (such as raising A1c targets) prior to the most recent level two event.
  • Beneficiaries with non-insulin treated diabetes and a history of at least one level 3 hypoglycemic event
  • The treating practitioner must document at least one of the following in the medical record:
    • The glucose value for the qualifying event (glucose <54mg/dL (3.0mmol/L)); or,
    • Classification of the hypoglycemic episode as level 3 event; or,
    • Incorporate a copy of the beneficiary’s BGM testing log into the medical record reflecting the specific qualifying event (glucose <54mg/dL (3.0mmol/L)); and,
    • An indication in the medical record that the beneficiary required third party assistance for treatment.

They also added the language that patient evaluations with the treating practitioner can be in-person or Medicare-approved telehealth visit with the beneficiary.

Continued Coverage

Coverage criteria for continued coverage notes “the treating practitioner conducts an in-person or Medicare-approved telehealth visit with the beneficiary to document adherence to their CGM regimen and diabetes treatment plan every six (6) months following the initial prescription for CGM. Medicare indicated that there is no requirement for the treating practitioner to reconfirm the initial coverage are met for continued coverage.

Modifiers

For blood glucose monitors (codes E0607, E2100, E2101) and related supplies (codes A4233, A4234, A4235, A4236, A4244, A4245, A4246, A4247, A4250, A4253, A4255, A4256, A4257, A4258, A4259) and CGM devices (code E2102 or E2103) and supply allowance (code A4238 or A4239), the following modifiers must be added to the code(s) on every claim submitted:

  • Use modifier KX if the beneficiary is insulin treated; or,
  • Use modifier KS if the beneficiary is non-insulin treated.

Contact The van Halem Group at info@vanhalemgroup.com for any questions.


TAGS

  1. medicare
  2. vgm
  3. wound care

From Our Experts

Fisher & Paykel Healthcare Launches New Selection and Sizing Tools in the F&P myMask™ App thumbnail Fisher & Paykel Healthcare Launches New Selection and Sizing Tools in the F&P myMask™ App The updated F&P myMask App* now offers mask selection and sizing in addition to the existing step-by-step education and support video content. VGM & Associates Announces Boone Lockard as VP, Clinical Services thumbnail VGM & Associates Announces Boone Lockard as VP, Clinical Services VGM & Associates is excited to announce that Boone Lockard, CRT, has been promoted to VP of Clinical Services. EleCare and EleCare Jr. thumbnail EleCare and EleCare Jr. EleCare is an amino acid-based, hypoallergenic, nutritionally complete formula. When used as the primary source of nutrition, it supports growth and improves symptoms of infants and children. Wound Care 101: A Guide for DMEPOS Providers thumbnail Wound Care 101: A Guide for DMEPOS Providers VGM Wound Care presents a comprehensive program designed to assist members in effectively offering wound care products and services, meeting patient needs, and concurrently expanding their business revenue streams. Preventing Pressure Injuries: Your Guide to Pressure Injury Prevention Month thumbnail Preventing Pressure Injuries: Your Guide to Pressure Injury Prevention Month November is a significant month for healthcare professionals and caregivers around the world as it marks Pressure Injury Prevention Month, particularly on 2023 Worldwide Pressure Injury Prevention Day (November 16). Wound Healing Through Nutrition: Unveiling the Healing Power of Juven thumbnail Wound Healing Through Nutrition: Unveiling the Healing Power of Juven In today's episode, Heather Trumm, Director of VGM Wound Care, talks with Linda Murray from Abbott Nutrition about the important role nutrition plays in wound healing and how a simple drink can help heal wounds. The Case for Outsourcing CPAP Resupply Order Fulfillment thumbnail The Case for Outsourcing CPAP Resupply Order Fulfillment From cost savings to technological integration, there are a number of compelling reasons why outsourcing CPAP resupply order fulfillment can be a game-changing solution for providers. Breathing Life into Healthcare - Celebrating Respiratory Care Week thumbnail Breathing Life into Healthcare - Celebrating Respiratory Care Week Respiratory Care Week takes place Oct. 22-28, 2023, and the focus shifts to bringing attention to the invaluable contributions of respiratory therapists (RTs) and specialists.