August 20, 2013

Drill Down: Glucose Monitors Excessive Units Billed

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RAC Region A contractor Performant has posted an automated review regarding beneficiaries receiving diabetic supplies above the maximum allowable limits. The supplies in question are the glucose monitor test strips and lancets in quantities greater than maximally allowed and medically necessary every three months for beneficiaries who are currently being treated with insulin injections and who have not seen their physician within six months prior to having ordered the supplies. This audit issues references both the NHIC Local Coverage Determination (LCD) and its corresponding Local Coverage Article.

Local Coverage Determination (LCD): Glucose Monitors

To be eligible for coverage of home blood glucose monitors and related accessories and supplies, the beneficiary must meet both of the following basic criteria (1) – (2):

  1. The beneficiary has diabetes (ICD-9 codes 249.00-250.93); and
  2. The beneficiary’s physician has concluded that the beneficiary (or the beneficiary’s caregiver) has sufficient training using the particular device prescribed, as evidenced by providing a prescription for the appropriate supplies and frequency of blood glucose testing.

The quantity of test strips (A4253) and lancets (A4259) that are covered depends on the usual medical needs of the beneficiary and whether or not the beneficiary is being treated with insulin, regardless of their diagnostic classification as having Type 1 or Type 2 diabetes mellitus.

Coverage of testing supplies is based on the following guidelines:

Usual Utilization

  • For a beneficiary who is not currently being treated with insulin injections, up to 100 test strips and up to 100 lancets every three months are covered if the basic coverage criteria (1) – (2) above are met.
  • For a beneficiary who is currently being treated with insulin injections, up to 300 test strips and up to 300 lancets every three months are covered if basic coverage criteria (1) – (2) above are met.

High Utilization

  • For a beneficiary who is not currently being treated with insulin injections, more than 100 test strips and more than 100 lancets every three months are covered if criteria (a) – (c) below are met.
  • For a beneficiary who is currently being treated with insulin injections, more than 300 test strips and more than 300 lancets every three months are covered if criteria (a) – (c) below are met.

Basic coverage criteria (1) – (2) listed above for all home glucose monitors and related accessories and supplies are met; and,

The treating physician has seen the beneficiary, evaluated their diabetes control within six months prior to ordering quantities of strips and lancets that exceed the utilization guidelines, and has documented in the beneficiary's medical record the specific reason for the additional materials for that particular beneficiary; and,

If refills of quantities of supplies that exceed the utilization guidelines are dispensed, there must be documentation in the physician’s records (e.g., a specific narrative statement that adequately documents the frequency at which the beneficiary is actually testing or a copy of the beneficiary’s log) that the beneficiary is actually testing at a frequency that corroborates the quantity of supplies that have been dispensed. If the beneficiary is regularly using quantities of supplies that exceed the utilization guidelines, new documentation must be present at least every six months.

If neither basic coverage criterion (1) or (2) is met, all testing supplies will be denied as not reasonable and necessary. If quantities of test strips or lancets that exceed the utilization guidelines are provided and criteria (A) – (C) are not met, the amount in excess will be denied as not reasonable and necessary.

NHIC Local Coverage Article: Glucose Monitors - Policy Article - Effective July 2011

For glucose test strips (A4253), 1 unit of service = 50 strips. For lancets (A4259), 1 unit of service = 100 lancets.

Manufacturers often include sample amounts of glucose test strips, lancets, and other supplies with a new glucose monitor. Claims for supplies included in the new monitor “kits” must be coded A9900.

RAC issues for the week of August 19–August 23, 2013:

RAC Region A Performant

DME Supplier

  • Beneficiaries Receiving Diabetic Supplies Above the Maximum Allowance - Jurisdiction A - Potential incorrect billing occurred for claims reporting quantities of test strips and lancets greater than the maximum amounts that are considered to be medically necessary every three months for beneficiaries who are currently being treated with insulin injections and who have not seen their physician within six months prior to having ordered quantities of strips and lancets that exceed the utilization guidelines, per NHIC's Local Coverage Determination (LCD) L11530 and related article A3314.
  • Home Health Consolidated Billing and Medical Supplies - DME Supplier - Jurisdiction A - According to the Medicare Benefit Policy Manual, Chapter 7, Section 10.11 (B) (Home Health Services Consolidated Billing), all medical supplies (routine and non-routine) are bundled to the Home Health Agency (HHA) episode payment rate while the patient is under a home health plan of care. Payment is made to the HHA and there is no separate payment to the DME Suppliers.

 

RAC Region C Connolly

Inpatient Hospital

  • CMS Pre-Pay Demonstration: MS-DRG-391- Esophagitis, Gastroenteritis, and Miscellaneous Digestive Disorders w MCC - The Recovery Audit Prepayment Review Demonstration will allow Medicare Recovery Auditors to review claims before they are paid to ensure that the provider complied with all Medicare payment rules. The demonstration has been approved with the following limitations: • CMS approves all issues for review; and • The issues reviewed have a high Comprehensive Error Rate Testing (CERT) rate The demonstration will begin initially with short-stay inpatient hospital claims in the seven Health Care Fraud Prevention and Enforcement Action Team (HEAT) states (Florida, California, Michigan, Texas, New York, Louisiana, and Illinois) and one state in each of the four Recovery Audit jurisdictions with the highest number of inpatient stays (Pennsylvania, Ohio, North Carolina, and Missouri). Initial claims selected for review will be those billed with the top Medicare Severity Diagnosis Related Groups (MS-DRGs) on the CERT report. The first edit that Fiscal Intermediaries (FIs)/ Part A and Part B Medicare Administrative Contractors (A/B MACs) shall install is for claims that meet the following criteria: • Billed with MS-DRG-391- Esophagitis, Gastroenteritis, and Miscellaneous Digestive Disorders w MCC • Length of stay is two days or less; • From providers who practice in the applicable demonstration state(s) only. RACs WILL ALSO REVIEW documentation for DRG Validation requiring that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Auditors will review claims for principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the focused MS-DRGs.

Inpatient PPS

  • Minor Surgery and Other Treatment Billed as an Inpatient Stay - IOM 100-02, Chapter 1, Section 10, states “Minor Surgery or Other Treatment - When patients with known diagnoses enter a hospital for a specific minor surgical procedure or other treatment that is expected to keep them in the hospital for only a few hours (less than 24), they are considered outpatients for coverage purposes regardless of: the hour they came to the hospital, whether they used a bed, and whether they remained in the hospital past midnight.” Claims billed for minor surgical or other treatment are identified for medical record review based on risk of improper payment for inpatient care when outpatient care was provided. Claims for patients admitted through the emergency department are excluded. RACs WILL ALSO REVIEW documentation for DRG Validation, requiring that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.

IP Hospital

  • CMS Pre-Pay Demonstration: MS-DRG-391- Esophagitis, Gastroenteritis, and Miscellaneous Digestive Disorders w MCC - The Recovery Audit Prepayment Review Demonstration will allow Medicare Recovery Auditors to review claims before they are paid to ensure that the provider complied with all Medicare payment rules. The demonstration has been approved with the following limitations: • CMS approves all issues for review; and • The issues reviewed have a high Comprehensive Error Rate Testing (CERT) rate The demonstration will begin initially with short-stay inpatient hospital claims in the seven Health Care Fraud Prevention and Enforcement Action Team (HEAT) states (Florida, California, Michigan, Texas, New York, Louisiana, and Illinois) and one state in each of the four Recovery Audit jurisdictions with the highest number of inpatient stays (Pennsylvania, Ohio, North Carolina, and Missouri). Initial claims selected for review will be those billed with the top Medicare Severity Diagnosis Related Groups (MS-DRGs) on the CERT report. The first edit that Fiscal Intermediaries (FIs)/ Part A and Part B Medicare Administrative Contractors (A/B MACs) shall install is for claims that meet the following criteria: • Billed with MS-DRG-391- Esophagitis, Gastroenteritis, and Miscellaneous Digestive Disorders w MCC • Length of stay is two days or less; • From providers who practice in the applicable demonstration state(s) only. RACs WILL ALSO REVIEW documentation for DRG Validation requiring that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Auditors will review claims for principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the focused MS-DRGs.
  • CMS Pre-Pay Demonstration: MS-DRG-392- Esophagitis, Gastroenteritis, and Miscellaneous Digestive Disorders w/o MCC- The Recovery Audit Prepayment Review Demonstration will allow Medicare Recovery Auditors to review claims before they are paid to ensure that the provider complied with all Medicare payment rules. The demonstration has been approved with the following limitations: • CMS approves all issues for review; and • The issues reviewed have a high Comprehensive Error Rate Testing (CERT) rate The demonstration will begin initially with short-stay inpatient hospital claims in the seven Health Care Fraud Prevention and Enforcement Action Team (HEAT) states (Florida, California, Michigan, Texas, New York, Louisiana, and Illinois) and one state in each of the four Recovery Audit jurisdictions with the highest number of inpatient stays (Pennsylvania, Ohio, North Carolina, and Missouri). Initial claims selected for review will be those billed with the top Medicare Severity Diagnosis Related Groups (MS-DRGs) on the CERT report. The first edit that Fiscal Intermediaries (FIs)/ Part A and Part B Medicare Administrative Contractors (A/B MACs) shall install is for claims that meet the following criteria:
    • Billed with MS-DRG-392- Esophagitis, Gastroenteritis, and Miscellaneous Digestive Disorders w/o MCC
    • Length of stay is two days or less;
    • From providers who practice in the applicable demonstration state(s) only

RACs WILL ALSO REVIEW documentation for DRG Validation requiring that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Auditors will review claims for principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the focused MS-DRGs.

About the Author

Dr. Margaret Klasa is the medical director for Context4 Healthcare. She is responsible for the company’s business knowledge discovery unit for medical context as it relates to the daily development of data products and software for medical claims editing and coding, with an emphasis on clinical and regulatory guidelines for Medicare, Medicaid and commercial payors.

Contact the Author

Margaret.Klasa@context4.com

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Read 37 times Last modified on August 19, 2013