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Expert offers advice on navigating diabetes technology in practice
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AUSTIN, Texas — Diabetes technology, despite proven benefits for patients, comes with challenges for practitioners, including time commitment and low reimbursement, according to a presenter at the American Association of Clinical Endocrinologists Annual Scientific and Clinical Congress.
“It’s the best of times, but it’s also the most complicated of times,” Timothy Bailey, MD, FACE, CPI, director of AMCR Institute, California, and clinical associate professor at the University of California, San Diego School of Medicine, said during the presentation. “We’re having 100 times more data than most of us had when we started practice, and we need all kinds of software to sort out downloads from pumps, sensors and glucose meters.”
Uploading data
The evolving technology provides practitioners with lots of data from continuous glucose monitors and insulin pumps, but accessing and analyzing that data can be tricky and time-consuming, according to Bailey.
Most data from devices are downloaded in the office with various cables and dongles, which is time-consuming. Patients can have more than one device to download, which can delay an appointment even further.
Some devices are equipped with Bluetooth technologies that allow faster, wireless uploading of data, but this still takes time and is not yet widely available among devices, according to Bailey.
After the data are uploaded, physicians need software to analyze it. The most common software is that which comes directly from the device manufacturers.
“This is both a blessing and a curse,” Bailey said. “The device manufacturer knows their device the best, so their software is the fastest software, but it can be a curse, though, if you don’t like their reports. It can also be a curse because every company has a different form of a different report and it can be very confusing to your staff because you tell them, ‘Don’t print all the pages, just print this, this and this.’”
There are a few independent software companies, like Glooko and Tidepool, which can be used with most devices and are cloud-based.
Mobile apps are also an option for monitoring data. Some, which are designed by reputable companies, can provide tracking, motivation or insulin-dosing calculators. However, apps designed by independents can be harmful, Bailey said.
“Some of them are truly horrible. It’s a complete misunderstanding of how to report glucose data. The apps that recommend insulin doses are mostly untested and can be dangerous” he said.
These software options provide many different reports, and it is up to the physician to decide which are of value, Bailey said. Those choices then must be communicated to staff.
“You have to have a trained eye on what to print out. It’s a combination of telling your staff what to print and then understanding where the real meat comes from.”
Best practice in diabetes technology
Bailey made several recommendations on how to make a diabetes technology practice run as smoothly as possible.
To cut down on time spent downloading data in the office, devices with cloud technology are the best option, according to Bailey. Dexcom and Medtronic CGMs have apps that allow cloud uploading automatically.
“The data is in the cloud, and it means you don’t have to download it when they’re in the office. They can do that. And the best cloud products are when it just goes up there automatically. If the patient has to remember to hit the button before they come into the visit, they’ll forget to push the button before they come in for the visit,” Bailey said.
Hiring more staff to aid in downloading data and analyzing reports might be beneficial.
“You need space and you need staff to implement diabetes technology into your practice,” Bailey said. “In our model, we’re actually expanding. We now have three nurse practitioners and three physician assistants. We’re all going to have to learn to utilize additional non-physician staff more effectively to deliver great care cost-effectively”
For patients with very poor glycemic control due to incorrect insulin pump settings, Bailey recommended using the website opensourcediabetes.org. It is a free resource that will give consistent guidance for more optimal basal and bolus settings when inputting a person with type 1 diabetes’ weight, total daily dose of insulin and either HbA1c or average glucose.
“It’s not perfect, but it will at least give you a reasonable place to start,” Bailey said. “We find it extremely useful, particularly for those ... patients that you just have to start from ground zero.”
Navigating reimbursement costs
Reimbursement codes are limited for physicians wanting to initiate diabetes technology.
“All these devices are going to be much more implantable, and we have to be ready for those things and be excited, or else our specialty will not flourish,” Bailey said. “Additionally, we have to engage industry and patients to advocate for appropriate codes in reimbursement because we don’t have the horsepower or the money to do it ourselves.”
There are currently no codes for initiating insulin pump therapy or personal CGM, but there are options for initiating professional CGM and reading data.
First, to use the reimbursement codes, physicians must get authorization according to the state’s regulation.
For initiating professional CGM, which uses the office’s technology and where real-time data is not available, Bailey recommends setting up three visits for the patient. During the first visit, a nurse practitioner or physician assistant would hook up the professional CGM. During the second visit, the CGM would be unhooked. Together, these visits would be billed with a 95250 code for initiating CGM. The second visit would also be coded as 95251 for reading and analyzing the data, which must be done by a nurse practitioner, physician assistant or clinical nurse specialist. Then, within a few days, the individual would come back for a follow-up appointment that would be billed as an Evaluation and Management (E/M) code.
“What we think is important is that the hooking up, unhooking and data download don’t happen the day of the visit,” Bailey said. “Make it like an electrocardiogram, and we have our nurse practitioner read them. Again, it’s all about making things as inexpensive as possible because the present codes provide only modest reimbursement.”
For personal CGMs, those which are worn on the individuals and provide real-time data, Bailey recommends using two codes: one for downloading and interpreting the data (95251) and the other for a follow-up visit (99211, 99212, 99213, 99214, 99215). Unlike with professional CGMs, these would all happen on one visit, with the download being handled by a nurse practitioner or physician assistant. This method also allows individuals to download data from their CGM, pump and any other devices all under the CGM data downloading code.
Device companies offer resources
Another cost-saving option is to use resources available from device companies when initiating CGM or insulin pump therapy.
The use of a company representative to initiate CGM is time and cost saving, and this option is also available for pump therapy , according to Bailey. The point is that endocrinologists have to make the most of every available resource to be able to provide the best level of care for their patients.
Bailey concluded his presentation by highlighting the benefits of a diabetes technology practice.
“The optimal use of technology is an exciting opportunity to provide great benefit to people with diabetes. However, since reimbursement is currently poor, implementing the technology cost-effectively is challenging. You actually can more than break even, with the appropriate use of E/M codes, more frequent visits, and by billing for the work of downloading and interpreting CGM data with the correct CPT code,” he said. – by Cassie Homer
Reference:
Bailey T. W12. Presented at: AACE Annual Scientific and Clinical Congress; May 3-7, 2017; Austin, Texas.
Disclosure: Bailey reports receiving consulting honoraria from AstraZeneca, Bayer, BD, Calibra, Lilly, Medtronic, Novo Nordisk and Sanofi; speaking honoraria from Abbott, Insulet, Lilly, Medtronic, Novo Nordisk and Sanofi; and research support from Abbott, Ambra, Ascensia, BD, Boehringer Ingelheim, Calibra, Companion Medical, Dexcom, Elcelyx, Glysens, Janssen, Lexicon, Lilly, Medtronic, Novo Nordisk, Sanofi, Senseonics, Versartis and Xeris.