From the Medical Director
Glucose Monitor Supplies
In 2010 the New England Journal of Medicine published the results of a much-awaited study of intensive control of blood glucose in Type 2 diabetics and the impact on cardiovascular events. The Action to Control Cardiovascular Risk in Diabetes (ACCORD) study followed over 10,000 patients and was discontinued prematurely when interim analysis at 3.5 years demonstrated higher mortality in the intensive therapy group.
The ACCORD study adds to our body of medical evidence associated with blood glucose levels and the risk and benefits of tight control. The medical literature is unclear with respect to the appropriate frequency of testing of blood glucose levels in patients who are non-insulin dependent. In fact, the American Diabetes Association (ADA) makes no recommendation on how often patients who are non-insulin using should test nor do any physician or professional societies. Moreover, many studies confirm that testing more often than daily has no impact on glucose control and is a financial burden to the patient.
Why is this important? Medicare spends millions of dollars for glucose monitoring supplies, the majority of which are paid for supplies for testing more often than once per day in non-insulin treated diabetics. In Jurisdiction B, CGS Medical Review has an ongoing initiative of intensive claim review and education about the proper utilization of glucose monitoring supplies. This review is centered around claims for high utilization of HCPCS code A4253 (blood glucose test or reagent for home blood glucose monitor, per 50 strips). Suppliers are reminded that the Blood Glucose Monitor local coverage determination (LCD) outlines the maximum amount that most beneficiaries will need based upon typical testing frequencies. Beneficiaries who fall into one of the following categories are considered high utilizers:
- Beneficiaries who are not insulin-treated (KS modifier present) and whose prescribed frequency of testing is more often than once per day; or,
- Beneficiaries who are insulin-treated (KX modifier present) and whose prescribed frequency of testing is more often than three times per day.
For beneficiaries who require additional glucose monitoring supplies because of a higher than usual testing frequency, the following additional documentation requirements apply:
- The treating physician must see the beneficiary, evaluate their diabetes control within 6 months prior to ordering quantities of strips and lancets that exceed the utilization guidelines, and document in the beneficiary's medical record the specific reason for the additional materials for that particular beneficiary; and,
- If refills of quantities of supplies that exceed the utilization guidelines are dispensed, there must be documentation in the physician's records (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) that the beneficiary is actually testing at a frequency that corroborates the quantity of supplies that have been dispensed. If the beneficiary is regularly using quantities of supplies that exceed the utilization guidelines, new documentation must be present at least every six months.
Please note that the medical information justifying that high utilization is reasonable and necessary must be documented by the treating physician in the beneficiary's medical record. Supplier-generated records do not meet this requirement.
Suppliers are also reminded that they are obligated to monitor actual utilization and not just automatically dispense a set quantify on a set schedule. This responsibility includes staying attune to changes or atypical utilization patterns. While the LCD does not require suppliers to obtain renewal orders at predetermined intervals, suppliers are encouraged to periodically verify that high utilization continues to be warranted.
A new detailed written order is required when there is a change in the testing frequency, a change in the supplier, or a change in the treating physician. A detailed written order for blood glucose testing supplies must contain all of the following elements:
- Beneficiary's name;
- Prescribing physician's name;
- The item(s) to be dispensed;
- The specific frequency of testing ("as needed" or "PRN" is not acceptable);
- Quantity to be dispensed;
- Number of refills;
- The treating physician's signature;
- The date of the treating physician's signature (must be personally entered by the physician);
- A start date of the order – only required if the start date is different than the signature date.
If the order includes a standard glucose monitor (HCPCS code E0607), the detailed written order must also include the prescribing practitioner's National Provider Identifier (NPI) and the supplier must obtain a copy of this order prior to dispensing the monitor.
It is not necessary to include the ICD-9 diagnosis code of the condition that necessitates blood glucose testing on the detailed written order. This information, however, must be included on each claim for the monitor, accessories and supplies.
Refer to the Glucose Monitors
LCD and Chapter Three of the Jurisdiction B Supplier Manual
for additional information.
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