Sticky Issues

If you provide diabetic supplies to your patients, you can expect to receive an audit based on medical documentation and other components of the patient’s file. Let’s review how a patient qualifies for diabetic supplies, the documentation that should be present in the patient’s file and what you will need to provide when you receive one of these audits.

Medicare reimburses for insulin-dependent and non-insulin-dependent diabetic patients if they meet the medical coverage criteria. What qualifies a patient for a home glucose monitor and supplies?

• The patient has a diabetes diagnosis (ICD-9 code range 250.00-250.93) which is being treated by a physician;
• The glucose monitor and supplies have been ordered by the treating physician;
• The patient or caregiver has been properly trained or is scheduled to be trained on the use of the glucometer and supplies;
• The patient or caregiver is capable of interpreting test results in order to assure the patient’s appropriate glycemic control; and
• The device is designed for use in the patient’s home.

If the patient meets all of the above criteria, you must obtain a Physician’s Order per Medicare guidelines. If the patient requires more supplies than Medicare normally allows, then you will need to obtain a new PO or physician progress notes along with a copy of the patient’s testing log every six months stating why the patient medically needs to test more often than Medicare’s normal allowances.

Inform your patients up front that you will require a copy of their test logs monthly in order for Medicare to reimburse you for the over-utilization. If you carry monitors that provide computerized downloads then that will suffice as appropriate documentation that your patient is compliant and Medicare should be paying for the amount of supplies needed.

Also make sure the physician is treating the patient for diabetes. I have witnessed many over-utilization audits on diabetic supplies this past year. If auditors review the patient’s testing logs and they truly were not testing the amount that has been billed and reimbursed, you may receive an overpayment letter. So, be very careful when dispensing over the recommended amounts.

For a non-insulin-dependent patient, Medicare will reimburse 100 strips and 100 lancets every three months. You must add a “KS” modifier to these claims. Make sure you span date all dates of services for all diabetic supplies.

For an insulin-dependent patient, Medicare will reimburse 100 strips and 100 lancets every month. You must add a “KX” modifier to these claims. For lancet devices, Medicare will pay for a replacement every six months. But let me warn you about manufacturer’s warranties on the lancet devices. Even if Medicare will allow one every six months, look at your manufacturer’s warranty and see how long it is for. Medicare will not pay for a replacement if it is still under warranty. A monitor should not need to be replaced but once every five years per the replacement chart provided by the DME MAC.

A 3×5 prescription is not enough for a diabetic patient’s supplies and/or monitor. The PO is required stating all of the information to prove medical necessity: the length of need, frequency of testing, all supplies including quantities, the monitor listed, patient’s ability to use the home monitor, patient’s insulin dependency status, whether or not the patient is an overutilization patient and the medical requirements of testing more than three times a day or once a day, physician’s information, patient’s information, etc.

The delivery ticket must also meet Medicare guidelines and be in the patient’s file, whether shipped or delivered or picked up by the patient. The Assignment of Benefits must be complete and an accurate signature must be present. Remember, you may need to obtain an ABN for your overutilization patients if you do not have the required medical documentation.

With increased audits from OIG and the BIU in our industry, verify that your staff understands the coverage criteria and your patient files are complete and audit-ready. Do not get stuck with an overpayment.

Jane Wilkinson-Bunch

(770) 366-0644 cell, [email protected]

Jane Bunch is vice president, HME consulting, for Atlanta-based CareCentric. A reimbursement specialist, Bunch delivers educational seminars worldwide, helps develop corporate compliance plans and serves as a consultant for fraud and abuse cases. She can be reached at 678/264-4495 or via e-mail at [email protected].