today's webinar, hosted by the Diabetes Technology Interest Group. I am Dr. Gwendolyn Jack, and to share a little bit about me, I'm an adult endocrinologist, and I serve as the lead of the Ambulatory Diabetes Program in the Division of Endocrinology, Diabetes, and Metabolism at Will Cornell Medicine in New York City. I also serve as an advisor at the ADA Diabetes Technology Interest Group. In the next slide, you'll see a glance of today's agenda, so I will first start off with a few announcements, and then I will introduce our experts in a few moments. The presenters will be taking questions from the audience at the end of the event. Please do not wait until the end of the session to send in your questions. Instead, feel free to go ahead and type into the Q&A box in your control panel. Please be sure to use the Q&A box and not the chat function for questions. During this announcement segment, we will use the chat box primarily to send you important links, and you can also use this area to chat with other attendees. Next month, we have another exciting webinar. The Diabetes Technology Interest Group will host a webinar on March 11th. This is the second in this series on integrating the use of CGMs in clinical practice, with a focus on addressing barriers and optimizing clinical workflow. This is an ADA member-exclusive benefit. Feel free to scan the QR code or see the link in the chat to view. Another benefit of ADA membership is connecting with members of the interest group on the Diabetes Pro Member Forum. This is a wonderful opportunity to continue the conversation about the topics that are covered in this webinar. Please see the link in the chat below. And finally, I would like to introduce today's panelists. First, we have Dr. Catherine Price. Dr. Price is originally from Georgia, where she earned her Bachelor of Science from Emory College and completed medical school at Mercy University. She trained in internal medicine at Wake Forest Baptist Medical Center, where she also served as chief resident and instructor. Now the medical director of the Diabetes and Endocrinology Center, Dr. Price specializes in diabetes and thyroid disorders. An ACNH certified endocrinologist, she performs thyroid ultrasounds and biopsies and conducts research in diabetes technology. She is very passionate about education and she actively teaches medical students, residents, and fellows. Next, we have Carrie Keyes. Carrie is a physician assistant at Atrium Health Wake Forest Baptist Medical Center in the section of endocrinology, diabetes, and metabolism. She began practicing in the field of endocrinology soon after completing her physician assistant studies at Wake Forest University School of Medicine. She developed a special interest in diabetes technologies and is passionate about connecting patients and healthcare professionals to these resources. In addition to clinical practice, she actively participates in clinical research for diabetes medications and diabetes technology. She has contributed to numerous journal and textbook publications on diabetes technology, accessibility, inpatient use, and telehealth technology. We are so fortunate to have both Dr. Price and P.A. Keyes. Well, thank you for that wonderful introduction, Dr. Jack. Let me pull up the slides we're going to share with you all today for our presentation. All right, and we'll get started. So, we are going to go over a lot with CGMs today and I'm excited about the upcoming ADA webinar as well because I think it's going to truly lead into the workflows for optimizing this in your practice. So, we'll review the impact that CGMs have on clinical practice. We're going to go over how to actually interpret these sensor data because you do get a tremendous amount of data with sensors, and then also look at documentation and billing for this. We've also got some data to present on 95251 utilization, which is the charge capture code for looking at 72 hours of data on sensors. We don't have any financial disclosures between myself and Kerry Keyes. And so, just to get started, there's a lot of sensors out on the market now. There's a lot of competition, which is honestly a good thing because the sensors keep getting better, smaller, more accurate. Of the ones that we see, there's a Libre, Dexcom, Eversense, and then Medtronic. The two that we see more often than not, I would say, amongst our primary care categories here are the Libre 3 and the Dexcom G7. Now, there are also some over-the-counter sensors, which we get asked about more frequently now that those are available. The Libre Lingo is over-the-counter for patients who do not have diabetes but are wanting self-glucose monitoring, as well as the Stelo is the Dexcom that is available over-the-counter. The Libre Rio is reported to be out sometime soon this year, and it is indicated for patients with diabetes, although not on insulin. And I'd say the caveat to know with these, just if your patients are utilizing the over-the-counter sensors, is that these do not typically come with alarm features if they're needing that for high or low glucose alerts. There's also a note that the Libre Professional is going to be discontinued, anticipated end of this year sometime between August, December, as best I know. And then of the other two we have on the right, the Eversense 365 that's approved FDA now for one full year of use. We are utilizing more in our clinical practice with having a healthcare provider who places those in office. There's also the Medtronic Guardian, as well as the Simpler sensor as well. So lots of options that you may see in your practice. So why CGM? So I think when we're looking at, you know, the impact of clinical practice, both Carrie and myself are very passionate about using these because we find that it truly optimizes the care patients are receiving for managing their own diabetes, for giving them more tools in their toolbox, so to speak. Well, if I do this, or I eat this, or I exercise, how does that affect my glucose level? And it gives them that trend in real time. And so if you're looking at the data and the literature, we can actually see an A1C reduction of one to 2% with sensory use alone, which is pretty incredible when you think about it. For the FDA, you know, for medication management, you need A1C lowering of 0.5%. This can be used as a tool for behavior change and modification for patients, as well as reduce hypo and hyperglycemic events for patients. As we'll see in one of our cases that we'll include later on, CGM can be used to overcome inertia because we're targeting something that we can measure, you know, closer to day-to-day rather than waiting every three months for an A1C. It also lends itself for remote monitoring, utilizing the 95251 code, which will cover more, but can truly help support our patients in optimizing their care. If we look at the diabetes standards of care that were released in 2025 through the ADA, really these devices should be offered to the majority of our patients. Some of the verbiage has changed over the years in terms of the strength of these recommendations. And for folks who are living with type 1 diabetes, it should be offered very early in the course of their disease, including time of diagnosis, which I'm not sure that everyone's doing across the board, but is remarkable when we do that, and patients get a lot of insight into how their glucose trends are going. Now, for those who are on insulin, it's also recommended either, you know, real-time or intermittently scanning, which would be the Libre 2. And then considering it, even for patients who, you know, have type 2 who are not necessarily on insulin, is also now included as a recommendation, given that we can see tremendous health benefits for those patients. A question we often get asked is, okay, well, sensors sound great. Now, how do I get my patients on a sensor? You know, is it covered? Is it not covered? That alone can be a lot to navigate. And so we've tried to consolidate that into a single slide, which I realize is a little busy, but we'll talk through that. So for commercial insurance, it really does vary by plan. Most commercial insurances do require one injection of insulin a day, and then a diagnosis of diabetes, whether that's type 1 or type 2, or gestational. And then some, you know, only require a diagnosis. It's something that we're seeing new. And so you may have patients in your practice who can have a coverage of a sensor through medical benefits with just a diagnosis of diabetes, not necessarily requiring insulin. For our Medicare patients, they do require one injection of insulin a day. This was a shift in the last few years. There was a big coverage expansion in April of 2023. And so it's outdated if someone is, you know, requiring for blood glucose checks and trending that. And so if you have one injection a day of insulin, it's covered for Medicare. You can also get sensors for patients who are with Medicare, if they're having significant hypoglycemia. And so that can be quite beneficial for those who may be having hypoglycemia for other reasons, not necessarily from insulin. So if you have a documented level 2 hypoglycemic episode for two occasions, so less than 54 on a glucose, and they were not responsive to treatment change, or if they've had one episode, level 3, such that their glucose was less than 54, but they also had altered mental status for required assistance. You know, maybe they had EMS, or, you know, another person had to help them treat their low glucose that was severe. That does qualify. Medicaid does vary by state. For Carrie and myself, we're in the state of North Carolina, where currently two injections of insulin are required, but this may vary based on where you're practicing. For uninsured or self-pay, or may not fall into one of these categories, but would like to have glucose monitoring, which can come up in our practice, even for patients who may have pre-diabetes, but are edging close to diabetes, but it's not covered under that diagnosis, there is a Freestyle Libre self-pay program where folks can get a two-sensor for $75. Often, this is a cost savings compared to some of the prices for the over-the-counter sensors, which I've listed below. Unclear of what the cost will be for the Libre Rio as of yet. So I'm going to turn this over to Carrie, who's going to update us on how to really get ready for using sensors in our practice. So obviously, we really love these sensors, but we know in order to get the most out of them, you have to be comfortable both with the technology, with getting your clinics ready, and then knowing what to do in your practice. So what that comes down to is getting yourself, your clinic, and your patients ready. And these are all really interconnected with one another. For your patients, ultimately, it's going to come down to choosing the right device for them and then giving them the support to be able to utilize that and get the most out of it. Generally, that means referring them to an education and CGM specialist. Within our clinics, that's primarily with our diabetes education team or our pharmacy team. In many other clinics, we do understand that there are trained staff on site. This may be nursing staff, medical assistants, but folks who are able to support the patients in getting set up with the devices and the apps. Generally speaking, samples are available from local representatives. So in many cases, that can be done at the time of the visit, and that really sets those patients up for success. Getting your clinics ready is going to be setting up your clinic accounts for each of the different sensors that we've talked about, training your staff, and then developing a workflow to really maximize accessing those CGMs and minimize the clinic delays. We are most likely to utilize these if that workflow is simplified, doesn't add extra time to our day and patient visits, and isn't going to get us behind. We typically do this by really encouraging remote access. I'm going to touch on that in a little bit, but getting these patients set up with the devices on their cell phones linked to our clinics so that those can be pulled up in advance. Generally, we do that as a bulk download. I think this is a great way for clinics to practice. We do it kind of the art of the pre-chart. So similar to how we may pull our patients up prior to a clinic day to see who we have coming in and make sure that we're familiar with their cases, our rooming staff, tech support, whomever it is that you and your clinics have selected as your technology support staff can pull all of those clinic downloads ahead of time so that they aren't adding additional time during the actual clinic visits themselves. And then where we are going to spend the bulk of our time today is really on getting yourself ready. And so this means knowing your prescribing basics, the insurance requirements, and then how to read the reports, how to document and interpret those reports, and ultimately how to bill correctly to get reimbursed for the time that you have spent utilizing this tool. So for getting our patients ready, as we said, there's lots of different devices and we want to select the best one for them. The three main ones that we're going to see on the market right now are the Freestyle Libre, the Dexcom, and the Eversense. Medtronic is in the process of coming out with a standalone sensor, but that isn't something that we'll be seeing much of right now. For the Freestyle Libre, this is available as an app on the cell phone or with a separate reader setup. Again, we generally recommend utilizing that app feature that allows for the remote connection with the patients so that we don't have to do a physical download in the clinic. Benefits to the Libre are the customized alarms. Do keep in mind those over-the-counter Libres do not have those alarms, and so if the patient is struggling with lows, those are not ones generally that you're going to want to encourage. The Libre is one of the most affordable ones for someone who is looking for a self-pay option with a prescription. The company does support folks to decrease that price down to $75 a month, and so that is one of the most affordable options for patients that don't have that good coverage. Dexcom is going to be the next one. This is a little bit shorter wear than the Libre at just 10 days, but does have those same options for the app or reader capabilities. Again, that over-the-counter is going to be app only and will have no alarms. That allows with these apps to do the remote links to the clinics. Dexcom's got a few more features than the Libre, but ultimately we get pretty good results from all. And then Eversenses are only implantable, so you would need to have a specialist in your area who's able to implant that unless that is something that you choose to go out and get trained for yourself. It is the only one with any on-body features, so it has an on-body vibration and does have a removable and replaceable transmitter. This is the only one of the options that does still require some calibrations, but those are fairly minimal. And so these are all great things to keep in mind. With each of those, they do each have their own platform. There are some platforms that are working on integrating these, but your clinic is going to need to download the accounts and set those up. Freestyle Libre uses an account called LibreView. There is a clinic account and separate provider accounts associated with that. You will have a clinic code that can be entered directly into the patient's app to connect them up such that you have that remote monitoring capability and you can coordinate that with the patients. Dexcom uses the Dexcom Clarity, so similar to that LibreView, it is an online account. This is a shared clinic account. Previously, the patients also needed to have that Dexcom Clarity, but with the newest device that's on the market, they can do so just through the app itself, which is a good time saver. And then lastly, we have the Eversense. They have their own portal. Again, a shared clinic access for that one. All right. So now that we've got our clinic more ready, we need to get ourselves ready. We're actually looking at the data, knowing how to document, and then also making sure that our staff understands this workflow as well. And so the 95249, we haven't talked about yet, but this is actually a charge capture code that is utilized during the training for personal sensor use. It's a reimbursable service. 95250 is used if you are interpreting a professional blinded sensor, which this is something, as the year goes on, we're going to be using less of because they're phasing out the professional blinded sensors. But it can be very helpful if we're looking at some glycemic data for someone who may not want to wear a personal sensor long-term. We're really going to focus more so on the 95251 that we've talked about earlier. So this is the charge capture code that is utilized if you are looking at 72 hours of data as a minimum when you're making your interpretation of that sensor data. This can be billed up to one time per month for when you're looking at the sensor data, and it must be connected to a diabetes diagnosis code, as well as include a note documenting your interpretation. Now, something we get asked a lot by folks who are not necessarily using these yet in their practice but would like to is, well, how do I code that? Where do I put that? What do I connect that to? And so the blue box we have here, so if you're seeing a patient and they're a return visit, maybe you would be coding them a 99214 for their level of service as a return patient, or say it's a new patient and it's a 99204. Whatever the level of service is, that stands alone from the actual interpretation of the sensor. We do put in what's called a 25 modifier with the level of service, and that simply tells our basically billing and coding that there is a separate service that we are also billing for. And so it depends on what type of electronic medical record system you're utilizing, but typically there's a section called charge capture where you would code this additional charge. And it would be the 95251. And then you would make sure that you've linked that to the diagnosis code for that visit. Now, if you're doing the remote monitoring, this may be a patient that you're not seeing in real time where there is no level of service. So you would not have a level of service for whatever type of encounter your EMR supports, including the 95251, which for us, we use Epic as our EMR, and there's a documentation only encounter that we utilize that if we're doing remote monitoring. Okay, so kind of dived into this already, but so for the remote monitoring, and this is something that can be helpful to learn as a skillset, I would say, for supporting patients and overcoming that inertia. So if folks are connected with a smartphone, then we are able to log into either LibreView or Dexcom Clarity or Eversense and take a look at their sensor data remotely. If they're using a reader, then the patient would actually need to either upload, and typically we do this at our clinic with either a dedicated nurse visit or a farm day visit, and they review at that time. We also occasionally will use the professional Libre more so in patients who just, they don't want a personal sensor. For whatever reason, but they're agreeable at times to a brief 14 day where to help manage their glucose trends. Okay, so now that we know how to actually build a charge, we wanted to review, what do we really need to include? What's mandatory? So you have to have at least 72 hours of data, and you have to have an interpretation of that data. Now, some of this may vary. So we've included a few templates to just go over, what can be a longer interpretation? What could be a very brief interpretation? The optional part is a snapshot of the actual ambulatory glucose profile report for AGP. Some of us at our clinic have a tendency to always include that because we're human and we love looking at that forest picture and we recognize trends, which I think is just a remarkable thing to be able to pull up, and even show patients in real time. Here's where your trend was before, here's where it is now. And so I personally like including that, but it's not required. And then recommendations are also in a way optional, because if you're seeing that patient in real time, you can document in your interpretation of the sensor, see assessment and plan for what the changes made that day. So if we're looking in this middle section, this has the reason for looking at the sensor, duration reviewed, what device they were on, includes their time in range, time below range, above range, average glucose, standard deviation, and then several other areas that could be updated. And so this is a bit of a longer format, but certainly would qualify and check all the boxes for the 95251 interpretation. And then we have one that's a little bit more brief, just to the right, where you could potentially, if you always know, well, I'm never gonna interpret one unless I have 72 hours of data. That is something you could potentially have in your template to pull in, and then document clearly the reasons for why, time and ranges there, observations, recommendations. And then an even more brief one is listed just at the bottom right. Now to include the one that we actually have templated at our clinic, this is an example of that. So we utilize something called a smart phrase within our EMR, and that pulls in this template basically. So you're not having to write this out every time. And so I think to Carrie's point on optimizing the workflow and well, how can I make this work, but be efficient, not be too cumbersome. I mean, certainly the repetitions of looking at sensors and doing these reports, you get better at it with recognizing these trends. But this is an actual copy of what we utilize at our clinic. And so it does pull in that we're looking at the full three days or more of our data, a comment on variability. We like to call out the GMI here, the glucose management indicator, that's a kind of a proxy for A1C, and then the time and ranges and our recommendations. And sometimes our recommendations are simply, the too much hyperglycemia, too frequent hypoglycemia in PLESI assessment and plan regarding changes we made during that visit. Right, to get to the goals in terms of when we're looking at this data, commenting on their time above range, time in range, time below range, it is important to have a good background knowledge and well, what do my goals need to be for the patient that's in front of me? And so this is a reference to the Battolino et al paper that came out in 2019 in diabetes care, that really set the stage for how to interpret glucometric data on sensors. So for those who have type one or type two diabetes and are not at high risk for hypoglycemia, they're not older frail individuals, our typical standard is to target time and range of 70%, because that gives us usually an A1C of approximately seven. It's ideal if we can avoid the hypoglycemic episodes by what's recommended as more of a guideline, less than 70 at less than 4% of the time, and then severe hypoglycemia of under 54, less than 1% of the time. And honestly, I use those two as my main targets. I know that we're going to have some degree of hyperglycemia for our patients. And so I try to normalize that with some patients, because some folks think they need 100% time and range, and that's not actually necessary. We tend to get more lows if we're targeting that. And then with our older patient population, some of these targets may be different depending on age, depending on frailty. And so 50% time and range is actually what's given as an A1C of roughly 7.9, 60% time and range would be 7.4. And then really targeting, minimizing those episodes of hypoglycemia, less than 1% is preferred for that type of a patient population. And we'll talk about this some later, but I think it's important to recognize when we say, well, 1%, well, how much time is that? That's about 15 minutes a day of hypoglycemia. If we're looking at 4%, while less than 4% is the goal of less than that, 4% is an hour a day of hypoglycemia. And so I think it's important to call that out when we're talking with patients for why I'm so concerned that you're having 2% hypoglycemia. Well, that's 30 minutes a day. That's a lot that you're having to take time away from your day to treat those to, yeah. Anyway, so I always call that out. And then for our patients who have diabetes and pregnancy, we do have very different ranges here for target. And so it's much more strict, 63 to 140 is preferred. And then 80% time and range is roughly A1C of 6.5 with our goal of being ideally A1C of, you know, less than 6 to 6.5 range for healthy outcomes for mom and baby. And I stole my thunder on the hypoglycemia because I just am very passionate about trying to avoid that for patients. But this again just calls out, you know, those goals and targets and how much time that is. Right, now I'm gonna turn it over to Keri and she's gonna walk us through how to look through more of the report than just our time and range. As we had looked at before, each of the platforms is going to generate a report that's individual to the Libre, Dexcom or Eversense. But there are components that you will see uniform across the board that are contained in each of these AGP reports. And there's really four main things that we recommend focusing on. And I generally recommend taking that as a stepwise approach, and you'll look at that report the same way each time. So first and foremost, it's just that active time. Has the patient been wearing the sensor for an adequate amount of time for you to look at that, interpret the trends and actually advise safely on changes. Based on the billing requirements, that's gonna be a minimum of 72 hours. And generally speaking, that is gonna be enough for you to at least identify if there are consistent patterns that are going into play. The second is that you will be looking at the glucose management indicator, which as Dr. Price alluded to, is sort of an estimation of A1C if they were to maintain that level of control for that full period of about three months. And then the coefficient of variation, which is going to tell you about the level of variability within those glucose trends. This is unique to the AGP because our A1C tells us nothing about variability. And this is one of the best features that we have. The goal or what would be considered a stable or safe level would be a coefficient of variation less than 36%. So when we start to see those numbers above that, we have to put up our little yellow flag and say, what's going on? Where can we find some patterns and make some adjustments here? We then take it to our time and ranges. So as Dr. Price showed us, we will see the time above, in and below range. And we want to look at that with the glasses of our patient's individual goals. Do we have a patient who's meeting those standard goals where I'm looking for 70% time and range, less than 4% below? Am I dealing with a patient who may be more medically frail, older? We need to be a little bit more cautious with those goals. Or am I supporting one of my patients who is pregnant? And then lastly, we have the beauty of looking at the actual tracings themselves. And that is where we are going to look for the patterns to see are there times that patient is consistently running high, running low, and starting to delve in with the patient's feedback to figure out what's going on and how we can support them to make some changes. So we're gonna walk through reading a report using those guidelines, using a patient example. So we had a patient with type 2 diabetes. He was on basal insulin and terzapatide. This is a patient with a standard health background. So we are looking to meet a time and range target of 70% less than 4% lows. And we can see here, he's not quite doing that. So let's walk through it. So first and foremost, can we actually utilize this data to make recommendations? In this case, we downloaded a two-week report. That sensor was active 96% of the time. So we have two thumbs up to keep going and look at the rest of the report. Next, we take it to the GMI and the coefficient of variation. In this case, the patient's GMI was 8.1%. If we translate that into that estimated A1c, this is a little bit above where we would have set his target for less than 7%. However, the additional information we get looking at that coefficient of variation is that he has really high variability at 43.5%. So he is exceeding that 36% target. And there's probably something going on that we need to change. Looking at the AGP report, we then take it into the time and ranges. As we said, this is a patient of standard health. We're looking for a time in target range of at least 70%. So he's not quite meeting that goal. We take it down. We can see he has only 3% lows, no critical lows. So he's within the standard guidelines. But we wanna see, is that happening around the same time? Is this a low percentage that we maybe accept or is there still something that we might want to change? So we have his patterns here. And Dr. Price and I always say, beware the downward fasting trend. And this is a flag in many cases, particularly when we see folks who are utilizing a basal insulin and no rapid acting insulin. So we wanna ask these patients, what does their schedule look like? When are they sleeping? When are they having meals? What did those eating habits look like? So we found out that this individual is sleeping from about 1 a.m. to 8 a.m. So that's when that downward arrow is happening. And generally having some pretty high carb snacks at night in an effort to decrease those lows that are occurring overnight. So we found a couple of patterns there. So when we're documenting, we would say downward trend in glucose with episodes of fasting hypoglycemia and trends of postprandial hyperglycemia, most significant after dinner. Based on these, we can then make recommendations. And as we said, this could go in your interpretation report. If this is during a visit, you may just put this in your plan. So for this patient, we said, we'll do a 20% reduction in the basal insulin. We may consider up titrating his GLP or consider sending him for some supports with lifestyle changes. And this is a great opportunity to engage that diabetes education and to help them understand that there is an opportunity to engage that diabetes education team or medical nutrition therapy to try to support this and utilize that CGM tool prior to considering additional medications. Okay. So now that we've talked a lot about sensors, one of the questions we actually had within our own group at Atrium Health Wake Forest Baptist is if we were actually using the sensors and utilizing them appropriately in the outpatient setting. We certainly noted, if you see here with our graph, this is actually the number of times we looked at a sensor. And this is a quarterly graph. So you can see, we started looking at a lot of sensors, 2018, 2019, and it continued to escalate and escalate and escalate. And so, we got curious about our own data. We began to get more curious about, well, how are other departments outside of endocrinology, now that we have, Medicare is covering sensors for patients on only one injection of insulin a day since 2023, has this picked up in internal medicine was a question we actually had for a quality improvement project. So when we pulled our own data, looking at, this is from 2024, the first bar, which seems awfully low, I know, compared to the other ones, this first set is actually the 95251 RVUs. So there's 0.7 RVUs per sensor interpretation. And so, we have our RVUs on one side on the left, and then to the right is the actual units billed. So that's the sheer number of sensors we looked at. For our internal medicine group, this was actually a significant improvement from 2023. In 2023, there were about seven sensors that were actually looked at and interpreted. I'm sure we looked at more, but the number that were actually a billable service where that was captured and the provider was reimbursed for the time looking at sensors was pretty low. We have since done a lot of education for internal medicine and primary care. And so we are seeing an uptrend in that as folks get more comfortable with looking at sensors. The second column you see, that is our academic endocrinology adult group that both Carrie and myself belong in. And so in 2024 in total, we looked at 5,366 sensors, which is a lot. It's gone up every year. Carrie and myself are passionate about sensors. And so we actually made up about a third or a little over a third of that number and continue to try to teach others. And the thing that I think folks lose sight of is in some ways, I mean, we're helping patients certainly by looking at the forest, by helping them achieve better glycemic control, but utilizing this is also beneficial on the provider side for being reimbursed for your time. If we look at the combined number of sensors between our academic adult endocrinology group that Carrie and myself are a part of, as well as there's more of a private practice group, this was almost a quarter million or so of reimbursement for looking at sensor data, just because we're looking at sensors. So I wanted to call that out. Our pediatric endocrine group also looking at a lot of sensors, but we may have a little ways to go with offering them to folks at initial diagnosis of type 1 is something that we're still pushing for. All right. So we're gonna also look at our national data because this is something that there's not a whole lot of it if you look in the literature. Actually, if you go to PubMed and just try to search CGM and 95251, there's not much that comes up. But I did find one study that looked back reviewing data on sensor use for commercial patients who were living with type 1 diabetes specifically. And they looked at a category from 2010 to 2013, and then looked at claims data from 2016 to 2019. And they did see a tremendous increase in those who are utilizing sensors. Of note, then it increased across the board, but certainly if you look at the younger generation, and so those age zero to 12, and then 13 to 17, it has increased the most. And so this is just goes to say that we're going to be seeing more sensors for those who are taking care of folks living with diabetes. All right. And with that, we're actually gonna go through two cases and then we will close up. So I'm gonna turn it back over to Keri. I think getting this all together and really understanding how we're looking at it so that we can both benefit the patients and make those recommendations and get the billing out of it. So here we have a 52-year-old patient with type 1 diabetes currently on multiple daily insulin injections. He was using Degladec 22 and a fixed dose with insulin aspart, three times a day, plus a correction scale. Generally, this patient was only eating about two meals a day. He was using a GLP as well with a copay card prior to some of the insurance crackdowns with coverage for off-label prescribing, and he had to come off of it. So shortly after coming off, this is what we see. So unfortunately, you can take a look at this and see there is a lot of up and down. There are days when he is high, high, high. He has significant drops afterwards. A couple of days where things look a little bit smoother, we're not having the significant peaks. So not as many clear patterns as we might like to see. We can see he's definitely not meeting his time and target range at only 37% of the time. His GMI is a bit high at 8.4, and he's edging towards that higher variability. I would generally call this a moderate level of variability. So we can utilize this to say not only you're a little bit above target, but there's not a clear pattern. What can we do and what recommendations can we make with this information that we probably couldn't with just an A1C and often can't even with just a few points in time to help improve the glucose control and improve their quality of life? So the decision was made to transition to carb counting. We utilized the basic rule of thumb, taking total daily dose into account. He was using about 45 units of insulin a day and started with a carb ratio of 1 unit for every 10 grams of carbohydrates. And this patient picked up on it pretty quickly. In doing that, we've outlined a few of the more recently updated days when the patient came back into clinic. And you can see there is a significant improvement in that time and range. Still having occasional excursions, and that's something that we'll keep working on. But we were able to really customize the patient's plan and improve their control utilizing this tool. Had we been doing this for documentation, we would have had multiple opportunities to bill for that, each with different interpretations, because we can do that once a month. We're doing that at the initial time and then at this most recent clinic visit where we saw the improvements. And for case two, this is another case that we wanted to include because it was amazing to see someone truly overcome inertia, that often we will see an outpatient at times when we have A1Cs that are this high. So this is a case of a 66-year-old female. She had A1C of 17.9 when she was referred to our clinic. On arrival to clinic, her glucose was 441. She had mild ketones and was not having abdominal pain, nausea, or emesis at that time, but certainly very high glucose trends. She had actually not been started on insulin prior to getting referred to our clinic, which is a whole nother story that we would love to educate others on in terms of how to help support these patients with severe hyperglycemia. So at her initial office visit, we did start a Libre in office, and we did teaching on that. And so that the 95249 that we spoke about earlier was utilized for that training. She was started on weight-based basal insulin, as well as starting a fixed amount and giving her correction scale. She seemed very motivated to get her sugars down and feel better, and we were uncertain at that time if she had type 1 or type 2 diabetes. We did some autoimmune testing for her and also referred her diabetes education since she had not yet received this. She also then followed up with a PharmD at our practice, which is a pattern that we typically use as a workflow for visits in between those with a provider, such that the PharmD does download, reviews the sensor, and then will send their note to the provider associated with that patient. And so it's actually the health care provider who is billing the 95251 if those visits are monthly. Now certainly sometimes these are more than monthly, as was the case with this patient. She actually came in closer to every two weeks, and so it's only once a month that you can do the 95251. But I just wanted to share her remarkable journey. So she was confirmed as having type 2. Type 1 was ruled out at her first visit back after two weeks. She started with an A1C of 17.9. Her glucose management indicator on that initial upload of her new sensor was down to 11.4. She was already feeling a good bit better in terms of having less polyuria and polydipsia. Her mealtime insulin was then up titrated. We started with a weight-based dose and then later found out more insulin resistance. She was also started on a GLP-1 receptor agonist, and that was up titrated as well. And so I wanted to share a screenshot of her frequent visits because this is a patient who was incredibly motivated, was given the tools to actually see the habit changes in real time affecting her glucose trends, and she achieved a GMI of 7.2 percent in less than three months, which is incredible and humbling to get to see patients have these wins and really claiming their own health. And so I wanted to share her story because I'm very proud of her. So this is something that we can use in our practice in terms of overcoming inertia and giving the tools to the patients to really help support these changes. I also wanted to share that we have noted a change in our clinical practice that for some of our patients who are undergoing surgery with A1C targets, on occasion some of our surgeons are also accepting these GMIs to indicate that we've greatly improved their glucose control without necessarily waiting the full three months before having another A1C. All right. And then wanted to also just highlight at the end of our talk that the ADA has a wonderful resource with a consumer guide that's available to patients if they're having challenges navigating, you know, well what sensors are available? And this includes more than sensors. I mean it includes medications, meters, pumps, you name it. But wanted to highlight that in case those on the call are not aware of this wonderful resource to give to their patients. And with that I will let Kerry wrap up. Right. So to wrap up and to just reinforce a couple key points. Obviously we really want to engage our teams. This is something that I think the next talk is going to talk a lot more about, really getting it into practice. And so, you know, we'll be excited to hear that. You want to make sure you're creating your template, saving your template, make it easy to utilize. You've got the tools now to interpret it. So the next question is who can do that? Right. I want to really emphasize that. It does need to be the medical care provider and this can be a physician, nurse practitioner, or physician assistant. If you have a patient in clinic who is seeing one of the diabetes educators, they are seeing a nurse educator, they are seeing a clinical pharmacist. Those are still opportunities that we can utilize this charge capture code. That billing and interpretation still needs to come from that physician, nurse practitioner, or PA. So they can drop that extra charge. The additional visit would be separate. So we highly recommend utilizing your team if you are on this call and you are one of those excellent support roles, get a champion on board. Other models that we see working and really playing out well, having a remote monitoring clinic that could be with you yourself. I know a lot of clinics use advanced practice providers like the nurse practitioners and PAs to do dedicated clinic times for doing insulin titration. That is something a physician could do as well. And so just setting aside time to look at those extra reports and maximize the support for patients, but also the revenue from that. So I've done the math because I'm always curious. And as Dr. Price said, you get 0.7 work RVUs per CGM billed. If you were to set just a small goal for yourself, so you were billing one CGM per day, four days a week, or perhaps you're doing one half day remote monitoring session every two weeks, you would be capturing approximately 134.4 work RVUs in a year just doing that. In many cases, we're worried about our RVUs meeting targets, you know, getting financial reimbursement, maybe holding back on vacations. That is the equivalent of approximately 70, seven zero level four clinic visits. Go enjoy your week of vacation. Get your billing in, maximize your time. You're using the resource already. You might as well get paid for it. So we thank you for coming in. And hopefully we've got some good questions coming in. We're ready to answer. Great. Thank you so much, Dr. Price and Carrie Keys. We do have a couple of questions already. The first question is, can we get better interpretation of CGM results if we add information on food timing, the type and the amount as well as activity record and diary for patients, especially when the patient is ambulatory? Yes, definitely. So it depends on how much the patient is engaging with their sensor. But yes, patients can actually log what time and how many units they gave their long acting, gave their rapid acting, had a meal, had an eating episode. And I think that's incredibly helpful if you have a patient who is willing to give you that data and utilize the app to the fullest extent. And that is unique to the apps. If you have patients using the readers, they unfortunately don't have those capabilities. So that's just another reason to push that. But sometimes when I have folks who do have a lot of variability or I can't quite figure out what's going on, I will just ask them to log that information for one week. Right. It's not something they have to do every every day, especially if we're not looking at it. But just one week prior to the visit, log all those eating episodes, log the insulin administered. And that can be really helpful because that will show up on the download and you can see all of that feedback. The second question we have here is, do the interpretation codes have to be visits that are prescribers or can a license CDC? Yes, but no prescriptive license bill. I think you touched on this point. Yeah, so the answer is no, you can complete that visit and loop in perhaps that patient's clinic provider. So their PA, nurse practitioner, a physician. That's typically the model that is used in clinics. So just forwarding that chart to them and they can actually go in after the fact and add that billing code to it. Thank you. And then another question, how would your approach when insurance denies payment for CGM interpretation? So that's something I actually haven't had come up as of yet. I say that I've had it happen on one occurrence and it was a missed bill for a patient who had type one or somehow the insurance did not crosswalk over 95251 for what it really was. But I don't know that I've ever had someone who was completely I've ever had someone who was completely denied on. Carrie, I don't know if you have. I haven't struggled with that. So my best feedback would be to take a look at what you are documenting and make sure that you're meeting all of the true criteria that's necessary. So, I mean, you saw our template that we use. We outlined that the 72 hours was included. That's actually one of the reasons that I like to include that snapshot as well, because that's all going to be in the note, not just the ability to reflect back on that information and then making sure that you are including actual identifiable interpretation with that. Thank you. And we do have a few minutes for additional questions. If you have additional questions, feel free to again include it in the Q&A box. I have a question. So how do you counsel patients, especially when they're able to review reports as well? How do you walk through that process with them? I do it exactly the way I just did with you. I am a big fan of turning my screen, having that report up there, and I will walk through exactly what we just looked at, especially for our patients who are really engaged. I think it's helpful for them to know what their goals are, right? They've heard in many cases for a long time, we've got to get your A1C down, we've got to get your A1C down. But what that really looks like when we're talking about the time and range, what average glucose are they looking for? So I walk through it with those same four steps with them. Same. And sometimes that's their homework assignment. So for some of our patients, if they've gotten to goal and they're doing great, they may need less frequent follow-up appointments with us. It may be a six to 12 month timeframe that we're seeing them and no longer every three months. And so often for some of those folks, they have a homework assignment to still look at their sensor and they know, if I'm having lows, I need to call Dr. Price. If I'm no longer at 70% for that time in that green target goal range, I should probably reach out. And so I think that's an important conversation to have to put the ball in the court of the patient, so to speak, for them to be aware of what those targets are. And I think it goes back to that initial question about the value of adding in data about the physical activity and the meal recording as well, because being able to review that data with the patient at the time of the visit really facilitates that shared decision-making process. Absolutely. Definitely. Excellent. All right. Well, thank you again. One last question that I have is, especially with the increase of over-the-counter continuous glucose monitors, how do you anticipate the workflow changing to accommodate the OTC CGMs if you anticipate a change in workflow? I know. So it's an interesting question. So I think for the folks that we're seeing in adult endocrinology practice, I don't know that we're going to see a lot of the over-the-counter ones, particularly in our clinic. But if you are in a primary care-based clinic, I think they're going to be seeing a lot more of them. And folks who may have prediabetes may not have prediabetes but be at risk for it because of a family member with it or other reasons. And so I'm not sure that we'll see as many of them in the adult endocrine side. I agree with that. And I think, too, that it doesn't necessarily change the workflow in terms of this billing and interpretation that we have looked at. What I think it will do from a primary care setting is really open up and invite more of that lifestyle conversation because the patients are already engaging and gathering that data. And so I think that's a great opportunity for primary care to have those conversations with patients and connect them with resources so that hopefully one day they don't have to see me. And it's an interesting thought, too, because we actually, there was a conference we had back in the fall, a local one at Wake, and one of the topics was actually specifically on using CGMs for de-escalation of therapy in patients with diabetes, primarily for those with type 2. But it was just a wonderful concept to think about and to support folks who are making significant habit changes. But again, I feel that most of those patients would probably be more so in the primary care type of a setting. And you both went over some fantastic clinical pearls. If there was one thing each of you would want the audience to leave with, what would that be? Oh, goodness. That's a tough one. I would say to not be fearful and just rip off the Band-Aid. If you're not used to using sensors in your practice, I mean, I get that it's an unknown and unknown things that you haven't utilized before that first time, it is nerve wracking. But you have to get the repetitions in to get good at it and to help support your patients. And your patients will teach you also because they're seeing all of that data in real time. I think to build on that, I guess my piece of feedback would be to say that these have actually made my job a lot easier. It is so much easier for me to make changes with patients when I have this wealth of information that I often didn't have before. And so you've already taken the time if you have them on a sensor to look at it. Takes a couple of minutes to build for it. So just build for it. Absolutely. And we have a couple more questions that just came rolling in. So one question is, what are you using as a replacement for LibrePro? Yeah, so generally, so we tend to get samples in the clinic. So we will often just pop a sensor on the patient, even if we're doing it just as a couple week trial. But the other option would be just to prescribe a personal sensor and have a patient come back for that review. And then last question, can a PCP bill for CGM interpretation on over-the-counter CGMs since they are not covered by insurance as of yet? Yes, as long as there's 72 hours of data that you're looking at. Well, thank you so much. Thank you for such a comprehensive review and discussion about the value of CGMs in clinical practice and the value of appropriate documentation and billing and really empowering patients to review the reports alongside to facilitate that shared decision-making process. Thank you again, Dr. Price and Kerry Keyes. Thanks for having us.

Continuous Glucose Monitors

diabetes management

CGM data interpretation

patient education

insurance coverage

sensor reports

billing documentation

shared decision-making

clinical practices