Glucose Monitors & Supplies Quarterly Results of Targeted Probe and Educate Review - JD DME
Glucose Monitors & Supplies Quarterly Results of Targeted Probe and Educate Review
The Jurisdiction D, DME MAC, Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of HCPCS code(s) A4253 and E2103. The quarterly edit effectiveness results from July 2024 - September 2024 are as follows:
Based on dollars, the overall claim potential improper payment rate is 33%.
Top Medical Necessity Denial Reasons
- Medical record does not include documentation to support the beneficiary is testing at a frequency that corroborates the quantity of supplies dispensed (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). Refer to Local Coverage Determination L33822 & Policy Article A52464.
- Medical record documentation does not support the need for the specific quantity of supplies that exceeds the usual utilization amounts described. Refer to Local Coverage Determination L33822 & Policy Article A52464.
- Medical record documentation does not support the beneficiary has had an in-person visit with the treating practitioner to evaluate their diabetes control and their need for the specific quantity of supplies that exceeds the usual utilization amounts within six months prior to ordering quantities of strips and lancets that exceed the utilization guidelines. Refer to Local Coverage Determination L33822 & Policy Article A52464.
Top Technical Denial Reasons
- No medical record documentation was received. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.2.3.8.
- Documentation was not received in response to the Additional Documentation Request (ADR) letter.
- Date of service for item(s) billed has been partially paid. Refer to CMS Manual Pub 100-02 Chapter 15, Section 50.5.1-50.6 & 110-140.
Educational Resources
Suppliers billing Medicare should be familiar with the documentation requirements and utilization parameters. Visit the Glucose Monitors webpage to access coverage documents (Local Coverage Determination (LCD), Policy Article, National Coverage Determination (NCD)); documentation letters, forms, and checklists; reviews; tips; tools; resources; related articles; and educational events and tutorials, if applicable.
See the CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3 information about probe/error validation reviews.
