Article Detail - JA DME

Dear Physician:

The Comprehensive Error Rate Testing (CERT), Contractor under contract with the Centers for Medicare & Medicaid Services (CMS), performs medical review for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) provided to Medicare beneficiaries to determine paid claims error rates for Medicare contractors and providers. It is your responsibility as the ordering physician to determine and document the medical need for all healthcare services.

The CERT Contractor may request that the supplier obtain this information from you in order to verify that Medicare coverage criteria have been met. The supplier must submit the documentation to CERT within 75 days from the date of the first initial request letter.

For Glucose Monitors and Glucose Supplies to be covered by Medicare, the patient's medical record must contain sufficient information about the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement (if applicable). As the treating physician, you are responsible for all of the following:

1. A complete order* that includes the following: 1) All item(s) to be dispensed;
   1. The specific frequency of testing;
   2. The treating physician's legible signature;
   3. The date of the treating physician's signature;
   4. A start date of the order - only required if the start date is different than the signature date; and
   5. The duration of need
   *Note: An order that only states "as needed" will result in those items being denied as not medically necessary. Also, a new order must be obtained when there is a change in the testing frequency.
2. Documenting that the patient (or the patient's caregiver) has successfully completed training or is scheduled to begin training in the use of the monitor, test strips, and lancing devices;
3. Ongoing documentation of the care and management of the patient's diabetic control;
4. Ongoing documentation that the patient is testing at home at the frequency ordered;
5. Documentation that the patient is testing at a frequency that exceeds utilization guidelines for insulin or noninsulin dependent patients must meet the following criteria:
   1. Documenting in the patient's record the specific reason for the additional materials for that particular patient.
   2. Documenting a face-to-face evaluation for the patient's diabetes control within 6 months prior to ordering quantities of strips and lancets, or lens shield cartridges that exceed the utilization guidelines.
   3. 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 patient is actually testing or a copy of the beneficiary's log) or in the supplier's records (e.g., a copy of the beneficiary's log) that the patient is actually testing at a frequency that corroborates the quantity of supplies that have been dispensed. If the patient is regularly using quantities of supplies that exceed the utilization guidelines, new documentation must be present at least every six months.

Utilization Guidelines:

1. 1. For a patient who is not currently being treated with insulin injections, up to 100 test strips and up to 100 lancets or one lens shield cartridge every 3 months are covered if criteria A-E above are met.
2. 2. For a patient who is currently being treated with insulin injections, up to 100 test strips and up to 100 lancets or one lens shield cartridge every month are covered if criteria A-E above are met.

For complete coverage information, you may access the Glucose Monitors and Glucose Supplies Local Coverage Determination (LCD) Policy (L11530) at the following web site: http://www.medicarenhic.com/dme/medical_review/mr_lcd_current.shtml

DMEPOS suppliers are your partners in caring for your patient. They will not receive payment from Medicare for the items that are ordered if you do not provide information from your medical records when it is requested. Furthermore, not providing this information may result in your patients having to pay for the item themselves. Finally, your cooperation is a legal requirement as outlined in the Social Security Act, the law governing Medicare:

In accordance with 42U.S.C. 1320C-5 (a) (3) and 1833 of the Social Security Act, as a Medicare provider, you must provide documentation and medical records to the CERT contractor upon request to support claims for Medicare services. It is your responsibility to obtain additional supporting documentation from a third party (hospital, nursing home, etc.), as necessary. Providing medical records of Medicare patients to the Comprehensive Error Rate Testing (CERT) contractor is within the scope of compliance with the Health Insurance Portability and Accountability Act (HIPAA).

You may not charge the supplier or the beneficiary to provide this information to the supplier.

Help your DMEPOS supplier continue to provide good service to your patients by promptly providing the information from your medical records that is requested.

DO NOT send medical records directly to the DME MAC.

Provide them to the equipment supplier who originated this request.

Thank you.