Glucose Monitors Draft LCD Raises Hackles

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BALTIMORE — Diabetic equipment providers will need to beef
up their documentation in order to get paid by Medicare if a draft
Local Coverage Determination on diabetic supplies is finalized,
stakeholders said last week.

The draft LCD,
released Sept. 23 by the four DME MACs, has some far-reaching
implications, according to John Norton, associate director of
public relations for the National Community Pharmacists
Association.

“The LCD does the following: [It] increases the documentation
requirements to obtain refills of test strips and lancets; requires
more documentation from the ordering physician for refills of test
strips and lancets; results in claim denials for the supplier where
the physician documentation is missing or deficient; and makes it
more difficult for beneficiaries to obtain larger supplies of test
strip and lancet refills,” Norton said.

Karen Kaczmarek of KBK Consulting in Boca Raton, Fla., a
registered nurse, said she had little quarrel with the limitations
on the amount of test strips and lancets patients can obtain.

“I can understand the reason for limiting and would agree that,
for the most part, most patients should test within the guidelines
here,” she said, noting that patients often stockpile supplies from
several different providers.

However, she said, “CMS added all this criteria about what has
to be documented in the physician notes. So what it really does
… is put the supplier in the middle. The supplier has nowhere
to go. They can’t tell physicians how to chart when they see
patients. To require that the supplier get all this documentation
from the physician is really unrealistic.”

For example, according to the draft LCD, “Home blood glucose
monitors are covered for beneficiaries with diabetes … if the
treating physician states that the beneficiary or caregiver is
capable of being trained to use the device in an appropriate
manner. If this requirement is not met, the glucose monitor and
related supplies will be denied as not reasonable and
necessary.”

Physicians are not always likely to state whether a beneficiary
or caregiver is capable of being trained to use a device
appropriately, stakeholders argue, and it is the provider who will
suffer as well as the beneficiary.

“If the physician doesn’t document properly or enough, he
doesn’t get penalized, he still gets paid for the visit,” said
Kaczmarek. “But the supplier gets their money taken back and they
can’t get it from the beneficiary without an [advanced beneficiary
notice].”

Such requirements place “burdens on suppliers that are the
responsibility of the prescribers,” Norton said. “CMS needs to
evaluate how to make sure that prescribers know the rules and are
held accountable for following them just like the suppliers,” he
said.

While the draft policy might appear more burdensome, Peggy
Walker, billing and reimbursement advisor for VGM Group’s U.S.
Rehab division in Waterloo, Iowa, doesn’t believe it is.

“It is not really any more than what has already been there.
It’s just that they are making it clearer,” Walker said. “This is
the way it is going to be from now on. All policies are going to be
reviewed, looked at and changed. That’s the reality.”

Still, though physicians are legally bound to provide
documentation, Walker said, it is hard for providers to push for
it.

“We’re customer-service oriented and we don’t want to make the
doctors angry and lose our referral sources,” she said. “That’s the
way you do business. But that’s not Medicare.”

The answer may be to involve the beneficiary by using an ABN
when necessary, Walker said. “We have to get the patient involved.
Once the patients start complaining, then you’ll see a change,” she
said.

Walker said she has heard from numerous providers complaining
about the glucose monitors draft LCD, but she believes it is early
to be too concerned. “What they have to do is wait until the draft
policy is over,” she said. “They are flipping out over something
that is not finished yet.”

Providers and others will get a chance to have their say. The
DME MAC medical directors are holding a joint open meeting on the
draft LCD Oct. 26 in Baltimore. Pre-registration is required and
will be accepted through Oct. 15. Information is available on each
of the DME MAC websites:

Comments, to be accepted through Nov. 8, can also be made by
e-mail to each jurisdiction’s DME MAC medical director.

Read the draft LCD and the medical directors’ letter about the draft
policy on the Jurisdiction A website.

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