Hello and welcome to this presentation titled practical strategies for incorporating C. G. M. Into practice. How can manage care physicians and pharmacists. Established center based C. G. M. In their managed care practice setting. My name is Diana Isaacs. I am an endocrine clinical pharmacy specialist and also the C. G. M. Program coordinator at the Cleveland clinic. So the objectives that we're going to discuss today are to first describe optimal processes to access C. G. M. For people with diabetes. Since we know access can be a real issue. Then we're going to discuss some of the coding and reimbursement opportunities for C. G. M. And then outline how the I. C. C. Framework which stands for identify configure collaborate can be used to address common barriers to C. G. M. So let's first talk about Boston access. The reality is C. G. M. can be expensive and even we have some lower cost options but even the lowest cost option typically cost about $130 per month without any insurance and that can often be too much for people to spend. So some insurance plans unfortunately limit it and have strict criteria such as only for people with type one diabetes. Now, fortunately we are seeing it expand Medicare as well as many many other pairs now are expanding to include type two diabetes although they they're often can be multiple requirements depending on the plan. So for example requiring multiple daily injections of insulin or for the person to be on an insulin pump or insulin treatment that requires frequent adjustments or ongoing visits to assess that adherence that have to be in person fortunately about a little over a year ago, Medicare removed one of the requirements that was really tough for people to obtain and that was the four times a day finger stick checking. That was tough for multiple reasons. It is not fun poking your finger so many times a day. But in addition to that often test strips were limited to three times per day. So that was very challenging for people to do that on top of the documentation environments. And also another change that maybe is not as widely known is that insulin was changed from multiple injections per day. Two administrations and the good part about that is that allows for people who are on inhaled insulin also to be included. Now we're also seeing bills or opportunities for even further expansion. So currently Medicare is evaluating if they want to expand this to peop well on once a day insulin. So that would be people on basil only regimens and we have a lot of good data showing the benefits of C. G. M. One of the landmark studies was the mobile study done in people with type two diabetes on basil, insulin showing better outcomes. A one C reductions increase in time and range on people on once a day insulin. So we look forward to hopefully seeing that and seeing other payers follow suit with that. So going on with some of the barriers to see Gm access another barrier is knowing how to get it covered by the plan. Because depending on the plan the way a person goes about it it could either go through the pharmacy benefits or go through the durable medical equipment side. The DME DME can pose a challenge in clinical practices. There often is a little bit of extra red tape in terms of additional paperwork to fill out documentation requirements. And sometimes it's not as easy as just putting in a script in the electronic medical record. It requires going through an outside system faxing paperwork and that can just be burdensome. And then in addition to that outside of you know prescribing it. Also many people may have copays or coinsurance or have to meet a certain deductible which can make it difficult. I call this the vicious cycle because I see this happen all the time in practice where a prescription for C. G. M. Is sent to the pharmacy. It's the scripted there. That part is easy and then it comes back saying okay we need a prior authorization. So we do the prior authorization but then it gets rejected and then everyone just kind of gives up at that point and says okay I guess this patient was not eligible for C. G. M. But actually in this case it was supposed to go through D. M. E. And in fact with Medicare it always is almost I should say almost always it's supposed to go through D. M. E. So it's really valuable to know that ahead of time to save some headaches and make sure that we are ensuring access for our patients. I want to share this example about really the importance of access. So this was a patient of mine who was on a hybrid closed loop insulin pump. So this is a pump that communicates with the C. G. M. To automate insulin delivery. And she was achieving 79% in the target range on this system and that's great. That's beyond the goal of 70% or more. So she's wearing the sensor that goes with this pump But then she became 65 and went on Medicare and Medicare did not pay for the particular sensor that goes with this pump. So she switched she had to switch her center to one that is not compatible with this pump but she was still using the pump Here was her updated the GM report. Now she is only 47% in range and if you add up the lows we actually add up to 17 and the eight, she's spending 25% of the time in hypoglycemia. And I tried to work with her to adjust her settings to resolve all this hypoglycemia and increase her time and range. But without the automation we were able to improve this a little bit. But unfortunately she was still experiencing a lot of hypoglycemia. Now I do have a good update to this story and that Medicare now does cover the sensors that go with the system and she went back on the system and is doing great. But this just emphasizes the importance of having the right sensor that goes with the right system and ensuring that people with diabetes have access to the technology, they need to have the best outcomes as possible. So some tips, some additional tips for success. So we know that C G. M coverage depends on the type of insurance and a good rule of thumb with commercial is a lot of times plans do cover it through the pharmacy. So I often advise people to start by sending the prescription to the pharmacy with Medicare start by going through a DME company and with Medicaid. Unfortunately because it state specific that really varies on plan. I know for us in Ohio we used to go through D. M. E. And now were readily able to go through pharmacy for many types of sensors but really to obtain the most up to date information connecting with the representatives from the various companies is super, super helpful to understand about the coverage landscape in each area and to just save time time to know where to send it to right away. So for example with Medtronic they have the Guardian connect and the Guardian three sensor, a Ciencia has ever since DEx come has the G six and Abbott has the library too and library three, so all of them have a whole salesforce of of sales reps as well as medical science liaisons that one can connect with. And also I enter pairs to really work with a variety of DME plans to really just make it easier for patients to be able to access this because it's working in the health system. It's a lot easier if we can just work with a couple de mes versus having to go with a different DME for each different type of insurance that can just make it the communication a little bit harder and then identifying a technology champion in the practice is super helpful because that person can connect with all these reps. Keep up to date contact information for any everyone because things change, there's turnover and also know, okay, this is how we prescribe it, this one goes through pharmacy or this is the DME plan that we're gonna work with and this is how we send it or we can set it up with our EMR so we can describe it as well as understanding the documentation needed and being able to communicate that with everyone versus each individual having to keep track of all of this information in their head in terms of DME documentation. So a certificate of medical necessity form is required and this is a standardized form. There are ways to put this into the electronic medical records. So it kind of automatically, a lot of this automatically populates depending on the play Then sometimes or I should say often chart notes are required, a couple of chart notes, but depending on the plan, some plans still do require glucose logs and that can go back 30 or 60 or 90 days depending on the plan. So that's just important to note and make sure that that's available. There are some creative solutions for when personal C G. M. Is not accessible to a person. For a variety of reasons whether it's that the plan, the insurance plan isn't covering it for their type of diabetes or it is covered. But the copay is not affordable for the person. And I wanted to bring up a quote from the standards of care which says use of professional C. G. M. Or intermittent use of real time. See GM are intimately scan. C G. M can be helpful in identifying and correcting patterns of hyper and hypoglycemia and improving a one C levels in people with diabetes on non insulin as well as basil insulin regimens. So that's what this is basically saying is it's not all or nothing sum C G M is better than no C G. M and will and can improve outcomes. So there's many ways to do C. G. M. I still say the best is if you can do it all the time and in fact there was a recent study, a follow up to the mobile study with basil people with type two diabetes on basil insulin showing that when they're C. G. M. Was taken away from them. Their outcomes started to decline. They're a one CS went up their time and range went down. So it still is better if we can get it more of the time. But that being said there's a lot of learning that can happen by seeing the data that can carry out carry over and if a person can wear it every three months for example or where one sensor a month that often can still be very valuable. So with professional C. G. M. Often that is a covered benefit by many plans 2 to 4 times per year. So that's a great thing to do. And then samples. A lot of practices do accept samples and that is a way to give people a taste of C. G. M. Or to help them if they run out of sensors or they're not able to afford it one month. And then each of the manufacturers do have discount programs as well as there's some discount pharmacy cards like single care or Good Rx. So there are multiple kind of creative ways we can help people with access. And one other thing about this because this happens a lot is someone will say gosh my sensor fell off early. I accidentally knocked on the door or I had to remove it for an M. R. I. What do I do? So in those cases the best thing to do is to call the manufacturer directly explain what happened and usually they will mail out another sensor. This is always going to be better than going to the DME company or the pharmacy which is often limited on being able to supply an extra sensor. So the next section that I want to talk about is quoting and reimbursement. So how do we how do clinics get paid for the C. G. M. Services And this is an important area because to sustain this uh the the clinic can obtain reimbursement that's gonna really be able to facilitate providing the best services for the patient. So here I've provided the codes for professional C. G. M. Billing and this is where the person is going to wear it on a short term basis it has to be worn for at least 72 hours to be able to build for the service. But depending on the sensor it can be worn for 10 to 14 days. There are two devices in this category. There is the lead pro which is a blinded device meaning the person does not see their data while they wear it and that one can be worn up to 14 days. And then there is the decks com G. Six pro which can be worn up to 10 days. The person has the option to use blinded or on blinded so they could see the data or it could be completely blinded to the person. So for the insertion for the device placement the code is the 9525 oh and this can be performed by a wide range of disciplines really. RN diabetes care and education specialist medical assistant physician. It's billed under the supervising physician, advanced practitioner or hospital outpatient department. And one caveat with this is you do need 72 hours of data to build this. So this code is typically build at the same time is the 95251 which is the billing code for the C. G. M. Interpretation. The interpretation is very specific that it should be performed by a physician, a nurse practitioner or physician assistant. However pharmacists in many states can do this with a collaborative practice agreement for example in Ohio we are able to do that and many other disciplines can be involved in what's called a preliminary interpretation discussing the data with the patient, providing some recommendations and sending that to the provider who ultimately can bill review and bill for that service for personal C. G. M. It's very similar except instead of the 95 to 50. Code, there's a 95249 code. So this also is for the hook up the sensor placement as well as education and training for this code you also need 72 hours of data to build and this also can be performed by a wide range of disciplines. RN pharm d. Dietitian diabetes care and education specialist, medical medical assistant for example under its built under the supervising provider and then the 95251 is the same code that's used for the professional. It's the C. G. M. Interpretation code and both of these codes are typically built together because you're gonna wait for that 72 hours of data before you build the 95249. A big difference with personal versus professional C. G. M. Is this 95249 code can only be billed once in the life of the device. So the 9525 oh for Professor GM can be built whenever you're inserting it, which according to many insurance plans could be two or four times a year. But this 95249 is once in the life of the device. But if a person upgrades for example, they go from library to library three, then it can be built again. The 95251 will also depend on insurance plans. It can be built up to once a month with some plans, some plans allow it to be billed quarterly. This is an example of the C. G. M. Interpretation documentation. Uh This is showing a summary of professional C. G. M. Findings and typically what we do with this is we show we will paste the ambulatory glucose profile report into the chart and then provide the summary of findings. So for example evaluating the average glucose. Is that a goal? The frequency of hypoglycemia and hyperglycemia and possible causes that may contribute to this as well as recommendations based on the data. And some additional tips for documentation are considered having a team member perform preauthorization and benefit verification with insurance companies for professional C. G. M. You could ask the patient to confirm if they have coverage. This is just a good idea. While most most plans provide coverage occasionally sometimes a prior authorization is required or if a person recently had this performed and is trying to do it again too soon. It may not get paid for. And then additionally Iain M. Codes. The evaluation and management codes can be build actually on the same day as C G. M code. So for example someone comes in. You're doing an irregular E. N. M. Visit but also evaluating or reviewing their C. G. M. Data that can we build as well using the 95251 codes. Um As long as you use the modifier 25 as long as a distinct and separate E. Mm service was medically necessary and provided over and above the C. G. M. Service which usually is the case. So piecing it together what does the workflow look like. So there's this great resource called the personal see Gm. Playbook that's available through the association of diabetes care and education specialists and an example of workflow would be the healthcare provider orders personal C. G. M. And then patient or pharmacist or vendor performs benefit verification with the insurance company. Uh So back in the day this was more common where we would just go to our sales rep and say can you verify what insurance plan they have? Uh That still happens with some of the companies but sometimes they want us to do that so that will depend. And then the devices either shipped to the patient or it's sent to the pharmacy. The person picks it up and then visit for device instruction and placement. And that could occur at the pharmacy that can occur through a virtual visit or it can occur in person in the clinic. If we have samples on hand, we will sometimes use the sample to provide this education and training and then send the script to the pharmacy or send it through the DME. Which then gets mailed to the person. And then we want to schedule a follow up at least 72 hours out. So we can build for the 72 hours of data that's required. Although usually we will make this at least a week or two weeks out. Two weeks is a great amount of time because it allows you to view more C. G. M. Metrics like the glucose management indicator for example and then you're gonna go ahead provide that interpretation and documentation. You can build a cpt code 95251. It's personal C. G. M. Also the 95249 and then adjust treatment based on the discussion with a person with diabetes. And that data provide a copy of the data to the person and and make sure they at least have an understanding of concepts like time and range and then providing ongoing support. So whether that's following up with the diabetes care and education specialist or someone else on the team. But a good rule of thumb is is trying to get another follow up at least within three months to review data and make any other changes. So that is kind of an overview of the coding and reimbursement. But one other opportunity is remote monitoring. So here's an example of this is actually taken from library view showing how within our dashboard we can see all kinds of amazing metrics and this can be customized looking at things like average glucose, the percentage of scans per day, how engaged a person is with the device you can look at time and range time below range or above Coefficient of variation, which is glucose variability. So the point is you could proactively reach out to people, you could organize your dashboard and say I want to look at all the people that are spending more than 5% of the time in hypoglycemia. I want to reach out to them and see what I can do to support them and help them. So they're not having so much hypoglycemia So you can get paid for this clinics can get paid for this. There are four remote monitoring codes and the ones most utilized for data. Like this would be the 99457 and 458. The reason why we don't use the 453 and 454 is because that is when you are providing equipment to the person and in this case the per person typically owns their own device. And so we are not building those codes but we are building the 457 and 458. And what this is is spending 20 minutes or more basically having interactive communication about the data and the 1st 20 minutes is 457 traditional is 458 and you can build up to 60 minutes per month. Most coders agree that you can build this in addition to the C. G. M. Interpretation code that 95251 as long as you are providing an additional service meaning someone is reviewing the data, discussing with a person and making, having that conversation, making recommendations such as lifestyle changes but having that on interactive communication with it. And this also can be performed by a wide range of disciplines similar to the 95 to 50. And 95249 codes but it does need to be built under a provider like an M. D. D. O. M. P. Or P. A. So one other area I want to talk about are some of the barriers to C. G. M. And a way to overcome those barriers are really to optimize a person's success with C. G. M. Is this I see see framework identify configure collaborate because we know just throwing technology at a person. Unfortunately in most cases does not automatically lead to to improved outcomes. So this is really basically very simple identify stance for identifying the right technology for the right person at the right time. So if you think back to that example of the person I showed earlier who was on an automated insulin delivery system, she needed the sensor that goes with her system. She did not need the wrong sensor. Uh And then once you've identifying the right technology, configuring it according to the user preferences treatment plan and that's really customizing those alarms, alerts and in different areas that can be tailored to the individual and then collaborating, having data driven conversations utilizing remote monitoring the C. G. M. Interpretation and really discussing and optimizing the treatment plan based on the data meaning we're doing something with it. Some considerations to take with a glucose monitoring device. So make sure you know if they're using a connected insulin pen or insulin pump, understand what is the right sensor that goes with that technology also what's important to the individual. Uh there's differences in terms of the frequency of sensor change so often ranging from 7 to 14 days, but there's one implantable option that goes 180 days maybe that's preferred by some people cost as well as the size of the sensor were getting smaller and smaller sensors. For example, Library three now is the smallest sensor. That's very important to some people being able to keep it discreet and not feeling like they're wearing something bulky. And then there's different customization with alerts and stuff. Some have predictive alerts and some don't. And so those are just other features that are important to some individuals. I didn't want to let you know about this amazing resource called diabetes wise Pro. And this can really help with that identify stage and it matches devices to patient considerations. There's actually a patient facing version and a professional version with a professional version. There's a device library and compare device tool where you can put in different things like oh is dexterity a big concern or the person is doing a lot of outdoor activities for eggs and see what technology may work better for the individual. There's also a comparison. So if you're wondering how to see gm sensors stack up directly to each other. You can do that comparison tool. And there's even steps that uh for prescribing that give you pointers on oh, based on this type of insurance, This is the documentation you need and this is how you can go about prescribing it. How many sensors do you need per month? Do you need a transmitter for example or a separate receiver? Now with configuring this will differ on the type of device. So it's great for the person to meet with the diabetes care and education specialist if possible. A lot of the companies have site representatives that can help the person and provide additional education and training or perhaps just someone in the office that's really an expert, that technology champion that can help. But you see on here this is an example of a G six. There's a lot of def choices in terms of you can have separate alerts at bedtime or during the day you can have rise rates or full rates. You can have it repeated a certain amount of time. And the key here is you want to make it useful but not burdensome where it's just alerting all the time and the person is ready to throw their sensor out the window because it is beeping and buzzing. It's waking up their partner and they don't like it so many times. I might even start with just having a low alert for safety and not even having a high alert. So again this will be individualized as well as many have the opportunity for data to be shared with um other loved ones or caregivers and so deciding how and who it should be shared with. So that third step of the I. C. C. Framework is the collaboration and this is again taken from the A. D. A. Standards of care which says no device used in diabetes management works optimally without education training and follow up and for this. I love to show that the example of a real person that I saw who was wearing a um wearing the sensor for about three months. So Camille was given a C. G. M. But not educated on her glucose turk, it's wearing it for three months. And this is the data when I see her and she was averaging 3 68 spending only 2% time in range with the rest of the time above range. But the sad part here is that Camille did not have the insight to to understand that this was not anywhere near the goal. And so she did she just waited the three months, she did not proactively reach out to anyone to say hey I think my treatment might need to be adjusted. And so whenever we are providing a device or prescribing a device we want to have that education about what are the glucose targets? What is time and range and what is the goal for that? And if you're not meeting the goal we should be following up sooner. So here's an example of where we did have sooner follow up and we were able to make changes. So this is an example of a person who if you look at the glucose management indicator at 6.2%. So that was the A. One C. And that was the data we had we might say oh this person is doing great like come back in six months right? But actually by wearing the C G. M. Were able to see that this person is spending 7% of the time in hypoglycemia below 70. And in fact we can see that that's really on this ADP is happening between three and around nine a.m. So by seeing this data and having the discussion about it we were able to decrease some of the basil insulin and improved to still maintaining an 86% in range. But we got that hypoglycemia to D Increased now to just 1%. The G. M. I went up a little to 6.7 but that's still well under 7%. And so having this data collaborating on it can really improve outcomes for people with diabetes. And this takes me back to the remote monitoring. So this is another example of how you can review on a spreadsheet your patients with C. G. M. C. Where they're averaging and even set up different flags. And so this is not only a billing and revenue opportunity for clinics but this really allows the clinic to be proactive at not waiting three months or six months to follow up with a patient but saying hey you're averaging a little high right now, let's do something about your treatment so we can increase your time and range lower your A. One C. And improve clinical outcomes. So there was a lot of information. Just some summary points. C. G. M. Can be prescribed either through DME or pharmacy and knowing which is preferred. Can save a lot of time for the practice and improve access for people with diabetes. There's several reimbursement opportunities for C. G. M. And that includes remote monitoring codes as well as those C. G. M. Specific cpt codes for professional C. G. M. And personal C. G. M. And then lastly the identify configure collaborate framework can really help people overcome many barriers to see GM use and here are some additional resources. The links for the diabetes wise and the diabetes wise pro websites to help with identification of C. G. M. Uh And then the ace guide to C. G. M. As well as A D. C. E. S. Has many. See GM resources including the personal and professional C. G. M. Playbooks and A. D. A. The american diabetes association has an entire time and range website with some wonderful webinars. So thank you so much for listening today and wishing you all the best
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