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:
- Jurisdiction A — www.medicarenhic.com
- Jurisdiction B — www.ngsmedicare.com
- Jurisdiction C — www.cignagovernmentservices.com/jc
- Jurisdiction D — www.noridianmedicare.com/dme
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.