Pharmacist Involvement in Continuous Glucose Monitoring Diana Isaacs, PharmD, BCPS, BC-ADM, CDE Endocrine Clinical Pharmacy Specialist

Learning Objectives Describe continuous glucose monitoring (CGM) and the clinical benefits for managing diabetes mellitus Explain the ways pharmacists can be involved in continuous glucose monitoring Discuss patient case studies and how CGM data is used to make clinical interventions Title: Pharmacist Involvement in Continuous Glucose Monitoring Presenter: Diana Isaacs, PharmD, BCPS, BC-ADM, CDE Learning Objectives: Describe continuous glucose monitoring (CGM) and the clinical benefits for managing diabetes Explain the ways pharmacists can be involved in continuous glucose monitoring Discuss patient case studies and how CGM data is used to make clinical interventions

What is CGM? Measures glucose in the interstitial fluid Records glucose reading every 5-15 minutes depending on device Up to 288 blood glucose readings per day! Get a look at how glucose responds to: Food Medications Physical activity Stress Helps to make medication adjustments, meal planning and stabilize blood glucose Records up to 5-15 minutes If dexcom, up to 288 BG readings per day 42 causes of BG fluctuations:

At least 42 factors affect blood glucose! There are several factors that affect blood glucose. Each person is unique and may have different responses from these factors. For example, one person may notice a spike in glucose after having black coffee in the morning or another person may notice that high intensity exercise actually raises glucose. Being aware of these potential factors and then seeing what patterns emerge on the CGM can be extremely helpful for managing diabetes. https://diatribe.org/42factors

Types of CGM Professional Personal Blinded and unblinded (real-time feedback) options Real-time feedback or scan for instant feedback (flash device) Short term use (3-14 days) Long term use Continuous monitoring Alarms for hypo/hyperglycemia in select devices Insurance coverage for most people with type 1 or type 2 diabetes Insurance coverage more limited to type 1 diabetes or those on MDI insulin Not compatible with smartphones or insulin pumps Compatibility with smartphones and insulin pumps with select devices Not FDA approved for insulin dosing (must always confirm with a glucose meter) Select devices approved for insulin dosing Explain difference between blinded vs unblinded Wright L et al. Diabetes Technology and Therapeutics 2017; 19:S-16-S-26.

CGM Options Professional Personal Dexcom G4 Medtronic IPro2 Freestyle Libre Pro Dexcom G5 Dexcom G6 Freestyle Libre Flash Medtronic Guardian Connect Medtronic Pump Integrated (Enlite/Guardian)

CGM Shared Medical Appointments (SMA) 2 Part Class Location: Cleveland Clinic Diabetes Center 5 (10) classes/ Month Profession CGM worn for 7 days Patients (4-5) Diabetes Educator (Nurse or Dietician) Pharmacist

CGM SMA Part 1 Class Time: 60 minutes Brief presentation on what to expect Do’s and Don’ts with CGM Logging food, activity, meds Conversation map Review of BG goals/A1C target Treatment and prevention of hypoglycemia/hyperglycemia Device insertion Calibration instructions Setting up high/low alerts

CGM SMA Part 2 Class time: 90 minutes Download devices/remove sensors Patients learn from each other Discuss “bright spots” and “landmines” Show report on the screen and interpret with the patients’ food/activity/medication logs Lifestyle/meal planning recommendations Medication adjustments Each patient gets a printed copy of their report and sent to ordering provider

CGM Program Outcomes Improved patient self-efficacy of diabetes Increased patient satisfaction “In the 20 years I’ve had diabetes, this is the best thing I’ve ever done.” Patient specific outcomes Optimize drug therapy Understand effects of foods on post-prandial BG leading to dietary changes and improved BG control Increased revenue Ongoing study to evaluate pre/post changes in A1C and diabetes self-efficacy scores

Professional CGM Billing CPT Code Services Who Can Perform Services 95250 Ambulatory CGM for a minimum of 72 hours; equipment provided, sensor placement, hookup, calibration of monitor, patient training, removal of sensor, and printout of recording RN/LPN, PharmD/RPh, RD, CDE or MA (if within their scope of practice), Physician, NP, PA: billed by the supervising physician, advanced practitioner or hospital outpatient department 95251* Ambulatory CGM for a minimum of 72 hours; analysis, interpretation and report. Physician, NP, PA There are 2 CPT codes required for professional CGM billing. The first is CPT code 95250 and it includes the CGM worn for a minimum of 72 hours, equipment provided, sensor placement, hookup, calibration of monitor if needed, patient training, removal of sensor and printout of the recording. This code is billed once the sensor is removed and the patient wore it for the full 72 hours. This service is often performed by diabetes educators, nurses, pharmacists, dieticians and medical assistance if within their scope of practice. IT can also be performed by physicians, nurse practitioners, or physician assistants. IT should be billed by the supervising physicians, advanced practitioner or hospital outpatient department. The second CPT code is 95251 and this includes the analysis, interpretation and report for the CGM device, worn a minimum of 72 hours. This must be performed and billed by a physician, nurse practitioner or physician assistant. The exception is that some profession such as pharmacists may be able to perform the service if allowed within the state’s collaborative practice agreement. In these situations, the CPT code is still billed under the healthcare provider. *Pharmacists can also perform interpretation via the OH pharmacy consult agreement, and co-signature of ordering provider https://www.aace.com/files/socioeconomics/new_revised_codes_2018.pdf

Personal CGM Billing CPT Code Services Who Can Perform Services 95249* CGM for a minimum of 72 hours, patient provided equipment, sensor placement, hook-up, calibration of monitor, patient training, removal of sensor, printout of recording RN/LPN, PharmD/RPh, RD, CDE, MA, Physician, NP, PA: billed by the supervising physician, advanced practitioner or hospital outpatient department 95251* Ambulatory CGM for a minimum of 72 hours; analysis, interpretation and report. Physician, NP, PA There is a new CPT code for 2018 that can be used to train patients on their personal CGM device. This code can be used only once for each patient wearing a CGM The CGM must be worn a minimum of 72 hours and includes patient provided equipment, sensor placement, hook-up, calibration of monitor if required, patient training, removal of sensor and printout of the recording. This requires an initial visit and follow-up visit for sensor removal and device download. The CPT code should be billed once the second visit is completed nor can it be used on placing the sensor initially.  *Report once per time the patient owns the equipment https://www.aace.com/files/socioeconomics/new_revised_codes_2018.pdf

Professional CGM: Cost & Revenue Cost of Supplies: Dexcom G4 kit ~$800 IPro2 system + 5 sensors~$999 Multiple patient uses/system 1 patient at a time Freestyle Libre reader: $65 Multiple patients can use 1 reader Product specific sensors needed for all systems: $60-$70/sensor Revenue: 95250 (CGM insertion) Medicare: $156.58 Private: $305 95251(CGM interpretation) Medicare: $36.72 Private: $90

CGM Patient Cases

Case 1: Making the Case to Start Insulin 54yo M Type 2 DM x 8 years DM Meds: Dulaglutide 1.5mg weekly Metformin 1000mg BID Glimepiride 8mg daily Empagliflozin 25mg daily A1C=9.2% This person with diabetes was only checking his blood glucose once a day in the morning and believed that his glucose was controlled -his readings were often around 150mg/dL. He did not like the idea of insulin injections. After wearing the CGM the patient was surprised to see how elevated his glucose levels were throughout the day and especially how much they spiked after meals. The recommendation was made to start the patient on 10 units of Lantus every evening in addition to his orals. Through encouragement by other patients already on insulin, the patient agreed to try it. The patient expressed how happy he is that he finally agreed to do it, and that his blood glucose is now well controlled. Patient was checking FBG once daily, always around 150, so he thought he was “doing ok”

Case 2: Impact of Food Choices on Post-Prandial Hyperglycemia 46yo with Type 2 Diabetes, A1C=7.5% Meds: Metformin 1000mg BID, Sitagliptin 100mg daily

Case 3: “Good A1C” but Low Time in Range 25yoM with type 1 diabetes A1C=6.6%, never brings in BG log Insulin glargine 16 units BID Insulin aspart: 1 unit for 9g CHO

Patient Quotes “I’ve lived with diabetes for over 30 years and wearing the CGM was the best thing that ever happened to me.” “I think every person with diabetes should wear one of these when they are first diagnosed. I learned so much.”

Summary CGM can improve clinical outcomes for people with diabetes Pharmacists can educate on CGM, download reports, and interpret reports CGM provides a unique billing opportunity for pharmacists Title: Pharmacist Involvement in Continuous Glucose Monitoring Presenter: Diana Isaacs, PharmD, BCPS, BC-ADM, CDE Learning Objectives: Describe continuous glucose monitoring (CGM) and the clinical benefits for managing diabetes Explain the ways pharmacists can be involved in continuous glucose monitoring Discuss patient case studies and how CGM data is used to make clinical interventions