Glucose Monitors 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 codes A4253 and E2103. The quarterly edit effectiveness results from October 2023 - December 2023 are as follows:

Based on dollars, the overall claim potential improper payment rate is 35%.

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.
  • KX modifier was incorrectly appended. Medical record documentation supports the beneficiary is non-insulin treated. Refer to 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.
  • 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.

See the CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3 information about probe/error validation reviews.

Last Updated Jan 29 , 2024