Article Detail - JD DME

Posted May 20, 2011

Recent data analysis for Jurisdiction A has identified instances where beneficiaries have received supplies that exceed the policy's usual utilization amounts. The policy recognizes that there may be occasions when a beneficiary may require greater than expected amounts. There are specific requirements associated with the provision of higher than usual utilization amounts. Claims experience has shown that many suppliers lack the required information in their files to justify payment for high utilization. This article is intended to serve as a reminder of the utilization amounts for Glucose Supplies and some of the commonly overlooked requirements.

Usual utilization for the most common items is:

• Insulin treated group, indicated by the KX modifier, at 100 strips/lancets per month
• Non-insulin treated group, indicated with a KS modifier, at 100 strips/lancets per 3 months
• A spring-powered device for lancets (A4258) is 1 device per 6 months.

These amounts represent the usual maximum amount that most beneficiaries will need based upon typical testing frequencies.

In audits, suppliers often lack records documenting their monitoring of beneficiary utilization and any adjustments made to refill frequency of quantities shipped. The policy requires,

"Suppliers must not dispense a quantity of supplies exceeding a beneficiary's expected utilization. Suppliers should stay attuned to atypical utilization patterns on behalf of their clients and verify with the ordering physicians that the atypical utilization is, in fact, warranted."

Another common deficiency noted is incomplete or missing prescriptions. All items billed require a detailed written order in the supplier's files before a claim is submitted. The order for home blood glucose monitors and/or diabetic testing supplies must include all of the following elements:

1. The item(s) to be dispensed;
2. The specific frequency of testing;
3. The treating physician's signature;
4. The date of the treating physician's signature;
5. A start date of the order - only required if the start date is different from the signature date.

An order that only states, "as needed" will result in those items being denied as not medically necessary.

A new order must be obtained when there is a change in the testing frequency.

Finally, the ICD-9 diagnosis code describing the condition that necessitates glucose testing must be included on each claim for the monitor, accessories and supplies.

Refer to the Glucose Monitors LCD and related Policy Article and the Supplier Manual for additional information.