The Jurisdiction A, DME MAC, Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of HCPCS code A4253. The quarterly edit effectiveness results from January 2023 - March 2023 are as follows:

Based on dollars, the overall claim potential improper payment rate is 51%.

Top Medical Necessity Denial Reasons

• The 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.
• The 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.
• Lancets, reagent strips, and other supplies necessary for the proper functioning of the device are also covered for patients for whom the device is indicated. There is no glucose monitor in the Medicare claims history and the narrative is missing, the claim is denied as missing the equipment that requires the supply. Refer to National Coverage Determination 40.2, Local Coverage Determination L33822, & Policy Article A52464.

Top Technical Denial Reasons

• Documentation was not received in response to the Additional Documentation Request (ADR) letter.
• No medical record documentation was received.  Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.2.3.8.
• The treating practitioner's order, Certificate of Medical Necessity, supplier prepared statement, or the practitioner's attestation, by itself, does not provide sufficient documentation of medical necessity. Refer to Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.9.

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.