Glucose Monitors & Supplies Quarterly Results of Targeted Probe and Educate Review - JA DME
Glucose Monitors & Supplies Quarterly Results of Targeted Probe and Educate Review
The Jurisdiction A, 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 January 2024 - March 2024 are as follows:
Based on dollars, the overall claim potential improper payment rate is 18%.
Top Medical Necessity Denial Reasons
- Medical record documentation does not support the beneficiary is insulin-treated or has a history of problematic hypoglycemia.
- Medical record documentation does not support the beneficiary has diabetes.
- The KX modifier was incorrectly appended. The medical record documentation supports the beneficiary is non-insulin treated.
Top Technical Denial Reasons
- No medical record documentation was received.
- Documentation was not received in response to the Additional Documentation Request (ADR) letter.
- Standard written order (SWO) is expired per length of need.
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.
