The Intersection of Technology and ReimbursementFriday, May 22, 2015
With insulin pumps and continuous glucose monitors (CGMs) becoming more widely used tools for diabetes management, providers need to be aware of the nuances of reimbursement for these new technologies. Reimbursement expert Patty Telgener talks about how to code for them as well as understanding other reimbursement opportunities.
By: Valerie Spain
As clinicians, you are tasked with keeping up with how the individual insulin pumps and CGMs can help your patients, but you have to know what you can be reimbursed for and the coding for them.
As this can be a tall task, we asked Patty Telgener from Emerson Consultants to share her insights on reimbursement for practitioners. She’s successfully lobbied for new legislation to secure reimbursement of new technology, worked with professional societies to obtain CPT codes and with Center for Medicare and Medicaid Services (CMS) to obtain ICD-9-CM codes, HCPCS codes and payment for new technologies. She also works directly with physicians, hospitals, and payers to ensure appropriate coverage and payment.
DiabetesCare.net spoke with her about how healthcare providers can successfully implement CPT codes for CGMs, understand why medical professionals may want to incorporate pump and CGM technology, and what might be in store for diabetes-related reimbursement opportunities in the future.
DiabetesCare.net: Can you talk about your professional background?
Telgener: I’m a nurse by training. I worked for eight years in pediatric intensive care and emergency room medicine. I decided to get an MBA and became a healthcare consultant with Deloitte and Touche. While there, I conducted hospital financial analyses and implemented new patient care delivery systems. And for 14 years after that, I was the director of reimbursement for Medtronic Neurological and Medtronic Diabetes.
DiabetesCare.net: Please tell us what you are doing now professionally?
Telgener: Presently I’m at Emerson Consultants, based in Excelsior Minn. At Emerson, we offer reimbursement, regulatory, clinical and market development consulting to the medical device, biologic, and pharmaceutical industries. I do a lot of work in diabetes. I was at Medtronic when the continuous glucose monitor was launched. Right now I’m also a coding consultant to the American Association of Diabetes Educators (AADE) and do reimbursement seminars.
DiabetesCare.net: From a reimbursement standpoint, is it a good time for providers who are currently not prescribing insulin pumps or CGMs to get into this area of diabetes treatment?
Telgener: I think it is a good time because more and more patients with diabetes are looking to technologies to help manage their diabetes. If you’re not offering CGM, newer insulins, like inhalable insulin, and you’re not aware of the most used apps, you are not able to offer your patients the latest technologies.
An insulin pump is considered durable medical equipment (DME) and there are no specifics codes for insulin pump training. However, pumps can make diabetes management more efficient which is important as physicians are pushed to see more patients and being held accountable for improved outcomes. CGM, on the other hand, does have specific CPT codes and can potentially generate revenue as well as improve outcomes.
If family practices and general practitioners are not able to incorporate this new technology into their practice, referring to an endocrinologist or diabetes clinic that has full treatment options may be better from a workflow perspective.
DiabetesCare.net: What about CGM billing and reimbursement, including specific codes? What CGM reimbursements do those codes cover?
Telgener: The CPT code for CGM are 95250and 95251.Most insurance companies cover CGM for type 1 as well as several insurance companies also offering CGM coverage for type 2 and diagnostic CGM for patients with non-insulin dependent diabetes. Medicare currently does not cover personal CGM but does covers diagnostic CGM. In diagnostic CGM, some brands blind the data (i.e. the patient won’t see data until they’re in the doctor’s office and it’s downloaded) and some brands allow the patient to see and interact with data in real time. Which brand to use is based on the provider’s preference or patient specific need.
DiabetesCare.net: And what should providers consider for insulin pump training, billing, and reimbursement? What are the specific codes, and what reimbursements do they cover?
Telgener: Right now, there are no specific codes for insulin pump training. Some training may be provided by the manufacturer or direct from physician office. If performed by a physician or mid-level practitioner, evaluation and management (E/M) codes may be appropriate or pump training may be part of DSMT or patient education.
DiabetesCare.net: In thinking about other diabetes related reimbursement opportunities, intensive behavioral counseling for obesity is now offered to Medicare patients. Can you explain how this works? Is this also applicable to other patients using other insurance?
Telgener: Patients don't need a diagnosis of diabetes to get this kind of counseling. So while intensive behavioral counseling doesn’t directly tie into diabetes care, because many obese patients have type 2 diabetes it can be offered as a complementary service. One thing unique here is, nurses and registered dietitians can’t bill for this counseling, only physicians, nurse practitioners or other mid-level practitioners can. This isn’t like diabetes education but rather it’s specifically a physician service.
Patients need a Body Mass Index (BMI) over 30 to qualify. Medicare also outlines specific details for how often a patient can be seen in a year. They begin as face-to-face weekly appointments during the first month, then less frequently as the year progresses, with the hope that such patients will take over their weight-loss program themselves.
Of course, practices are always looking for way to expand services they can offer, but insurance companies are equally reluctant to expand their list of providers who can bill for specific services.
However, I would say for physicians managing type 2 patients, it’s worth considering as a complementary service.
DiabetesCare.net: Are there other diabetes-related reimbursement opportunities, or conversely challenges, that providers need to be aware of in the near future?
Telgener: We all know that how healthcare is delivered and how it’s paid for is changing. The standard fee-for-service model means physicians only get paid when patients get sick. But healthcare is heading toward a prospective payment system and integrated systems that align incentives. The fact that physician, hospital, and payor may be one financial entity is changing how healthcare is delivered. In the new system, everyone wins by offering the most cost effective, high quality care.
Diabetes is beyond epidemic in this country, especially in pediatrics where adolescents are being diagnosed with type 2. Where will they be with complications in a few years? Providers can play a key role in diabetes management. New apps, web-based services, and new technologies will all work well under new delivery model. Diabetes has seen an increase in web-based education and telemedicine to increase access and compliance with technology. We are seeing payers adjust to this approach and are starting to see payment and reimbursement for these new technologies.
To find out more about Telgener’s services, email her at PattyT@emersonconsultants.com.