If you provide diabetic supplies to your patients, then you can expect to receive an audit from CMS or the DMERC 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 if and when you receive one of these audits.
Medicare reimburses supplies and a home glucose monitor for insulin-dependent and non-insulin dependent diabetic patients if they meet the following medical coverage criteria as set forth by DMERC policy: a) the patient has a diagnosis of diabetes (ICD-9 code range 250.00-250.93) that is being treated by a physician; b) the glucose monitor and supplies have been ordered by the treating physician; c) the patient or caregiver has been properly trained or is scheduled to be trained on the use of the glucometer and supplies; d) the patient or caregiver is capable of interpreting the test results in order to assure the patient's appropriate glycemic control; and e) 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 order every 12 months per Medicare guidelines. If the patient requires more supplies than Medicare normally allows, you will need to obtain a new physician order every six months stating why the patient needs to test more often than Medicare's normal allowances.
For a non-insulin dependent patient, Medicare will reimburse 100 strips and 100 lancets every three months. You must add a “KS” modifier to the claim. (Make sure you span date all dates of service for all diabetic supplies.)
For an insulin-dependent patient, Medicare will reimburse 100 strips and 100 lancets every month. You must add a “KX” modifier to the claim.
For lancet devices, Medicare will pay for a replacement every six months. But let me warn you about lancet devices: Even if Medicare will allow one every six months, it will not pay for a replacement if the device is still under manufacturer's warranty. A monitor should need to be replaced only once every five years per the replacement chart provided by the DMERC.
A 3×5 prescription is not enough to support claims for a diabetic patient's supplies and/or monitor. A physician order is required stating all of the information to prove medical necessity. This includes length of need, frequency of testing, a listing of all supplies and the monitor, whether the patient is capable of using the home monitor, if the patient is insulin dependent or not, if the patient is an over-utilization patient, physician's information, patient's information, etc.
The delivery ticket must meet Medicare guidelines and be in the patient's file, whether shipped, delivered or picked up by the patient. The assignment of benefits must be complete, and an accurate signature must be present. If the patient is an over-utilization patient, did you obtain a copy of the patient's test log? Do you have physician's progress notes on any of your diabetic patients?
Let's go over a post-payment audit that is sitting here on my desk and what the DMERC is asking for in this situation: 1) certificates of medical necessity (if applicable); 2) physician orders for services billed; 3) all medical records for dates of service listed; 4) manufacturer information (i.e., purchase invoice, package insert, brochures); 5) delivery slips; and 6) physician's notes (progress notes from the patient's file).
In the case of an audit, you will need to provide all of the paperwork requested by the DMERC by a specific due date. Be sure to review all documentation carefully prior to sending it to the DMERC. What you send in will determine the amount of your overpayment. Better now than later in your overpayment letter. The letter will list the patient's name, Medicare number, the equipment/supplies HCPCS codes and date(s) of service for which the DMERC is requesting this information.
Don't get stuck by a diabetic audit, whether you receive one in the mail or get a face-to-face or a faxed audit. Know what documentation must be in your patients' files, and know it meets the guidelines set forth by policy.
Jane Bunch is vice president, HME consulting, for Atlanta-based CareCentric. A reimbursement specialist, Bunch delivers educational seminars worldwide, helps develop corporate compliance plans and serves as a consultant for fraud and abuse cases. She can be reached at 678/264-4495 or via e-mail at jane.bunch@carecentric.com.
