Docs Tackle Logistics of Round-the-Clock Glucose Monitoring

As more patients with type 2 diabetes seek to reap health benefits from continuous glucose monitoring (CGM), primary care clinicians are learning how to incorporate these devices and the data they collect into practice.

Wider use of the technology means clinics need to address a range of elements that might seem mundane but could be crucial to successful adoption.

Certain billing codes might be less familiar outside of endocrinology. Current Procedural Terminology (CPT) code 95251, for example, covers the analysis, interpretation, and reporting by a clinician of CGM data, and can be billed monthly.

Some IT-type troubleshooting likely is needed as well. Having a designated member of the clinic staff who oversees requesting permission to access a patient’s data and making sure they can connect to the internet to transmit data from their CGM devices can help, according to Thomas W. Martens, MD, medical director of the International Diabetes Center in Minneapolis.

Physicians need a workflow that allows them to efficiently review CGM results with patients because this information is not yet readily accessible in EHRs.

More broadly, those trained to manage type 2 diabetes when glucose monitoring centered on occasional fingersticks must become familiar with using data that’s continuously collected.

Understanding how CGM results can inform patient care is quite intuitive, Martens said. He shared best practices on CGM during a session he conducted at the 2023 annual internal medicine meeting of the American College of Physicians in April.

More Primary Care Prescriptions

Martens has studied the use of CGM in type 2 diabetes, co-authoring a randomized trial of 175 patients treated with basal insulin. The MOBILE study, published in 2021, found that use of CGM led to significantly greater reductions in A1C, compared with blood glucose meter monitoring, over 8 months (−1.1% vs −0.6%).

Health insurers have been expanding the pool of patients eligible to use the devices. This April, Medicare began covering CGM for all beneficiaries with diabetes who use insulin or have a history of problematic hypoglycemia. Before, only those taking frequent daily insulin doses were covered.

More prescriptions for CGM for patients with type 2 diabetes have been originating in primary care.

"Despite evidence of an initial lag in CGM prescribing for type 2 diabetes in primary care compared to endocrinology, rates of primary care prescribing made up an increasingly larger proportion of incident users each year," researchers reported in a recent analysis of data from Vanderbilt University Medical Center.

Of 30,585 adults with type 2 diabetes in the VUMC health system, 13% had used CGM. "Primary care more than doubled its average monthly CGM prescriptions to new users in 2021 from the prior year," from 16.9 to 38, Lindsay S. Mayberry, PhD, associate professor of medicine at Vanderbilt, and co-authors reported in the Journal of General Internal Medicine.

In comparison, average monthly prescriptions in endocrinology increased more modestly during that time, from 45.3 prescriptions per month to 47.4.

Documentation Key to Coverage

CGM prescribing in primary care may be driven by patients who hear about the technology and request it from their doctors, according to Neil Skolnik, MD, professor of family and community medicine at the Sidney Kimmel Medical College in Philadelphia.

"The best way to figure out CGM is to prescribe it to a couple of patients and learn with them," Skolnik has said. He describes the learning curve for CGM as potentially more forgiving than that for prescribing a new drug because with a medication, clinicians must understand what they are using in advance, rather than being able to learn with patients along the way.

Anne L. Peters, MD, professor of clinical medicine at USC's Keck School of Medicine in Los Angeles, noted in a Medscape commentary last month that clearly documenting hypoglycemia can be key to getting CGM covered by Medicare.

Patients who have had an episode of severe hypoglycemia or at least two episodes of level 2 hypoglycemia with an attempt to adjust their medication to prevent future occurrences can be eligible for the devices.

Real-Time and Retrospective Insights

CGM technology "is widely used but that doesn’t mean we know how to use it well," Martens told Medscape Medical News. "That’s part of the learning curve. How do you help people to use this new and evolving technology in a way that’s really going to optimize its use and get maximum bang for your buck?"

While CGM provides patients with valuable real-time data, clinicians also should understand how to use retrospective data — at least three days’ worth of data are needed to use CPT code 95251 — to minimize hypoglycemia and evaluate how much time patients are spending in various glucose ranges.

Martens' group is working on efforts to incorporate CGM data into EHRs, which should make reviewing results with patients easier, he said.

While clinicians refine their use CGM in practice, one of the main benefits of CGM is what patients can see for themselves in the meantime.

For instance, a patient can eat a donut and watch their glucose go up, Martens explained.

"All of a sudden a person with diabetes can actually in real time see the impact of diet choices and lifestyle choices," he said. "That’s really powerful."

Martens disclosed research grants or contracts with companies that market or are developing CGM devices. Mayberry has consulted for Cecelia Health and received research support from the National Institute of Diabetes and Digestive and Kidney Diseases and the Helmsley Charitable Trust. Skolnik and Peters have disclosed ties to pharmaceutical and medical device companies.

American College of Physicians (ACP-IM) Internal Medicine Meeting 2023. April 27-29, 2023.

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