Sticky Issues

If you provide diabetic supplies to your patients, you can expect to receive an audit based on medical documentation and other components of the patient's file. Let's review how a patient qualifies for diabetic supplies, the documentation that should be present in the patient's file and what you will need to provide when you receive one of these audits.

Medicare reimburses for insulin-dependent and non-insulin-dependent diabetic patients if they meet the medical coverage criteria. What qualifies a patient for a home glucose monitor and supplies?

• The patient has a diabetes diagnosis (ICD-9 code range 250.00-250.93) which is being treated by a physician;

• The glucose monitor and supplies have been ordered by the treating physician;

• The patient or caregiver has been properly trained or is scheduled to be trained on the use of the glucometer and supplies;

• The patient or caregiver is capable of interpreting test results in order to assure the patient's appropriate glycemic control; and

• The device is designed for use in the patient's home.

If the patient meets all of the above criteria, you must obtain a Physician's Order per Medicare guidelines. If the patient requires more supplies than Medicare normally allows, then you will need to obtain a new PO or physician progress notes along with a copy of the patient's testing log every six months stating why the patient medically needs to test more often than Medicare's normal allowances.

Inform your patients up front that you will require a copy of their test logs monthly in order for Medicare to reimburse you for the over-utilization. If you carry monitors that provide computerized downloads then that will suffice as appropriate documentation that your patient is compliant and Medicare should be paying for the amount of supplies needed.

Also make sure the physician is treating the patient for diabetes. I have witnessed many over-utilization audits on diabetic supplies this past year. If auditors review the patient's testing logs and they truly were not testing the amount that has been billed and reimbursed, you may receive an overpayment letter. So, be very careful when dispensing over the recommended amounts.

For a non-insulin-dependent patient, Medicare will reimburse 100 strips and 100 lancets every three months. You must add a “KS” modifier to these claims. Make sure you span date all dates of services for all diabetic supplies.