Glucose Monitors & Supplies Pre-Pay Review Quarterly Status Report
Below is the analysis of claim denials for continuous blood glucose monitor HCPCS code E2103, A4239 and blood glucose test strips HCPCS code A4253 reviewed July 1 – September 30, 2024. The error rate for this quarter is 28.65%. The top 10 reasons for claim denials are as follows:
Rank | Reason | Percent |
---|---|---|
1. | We did not receive any medical record documentation. | 33.92% |
2. | The medical record documentation does not support the beneficiary had an in-person or Medicare-approved telehealth visit with their treating practitioner to assess adherence to their continuous glucose monitor (CGM) regimen and diabetes treatment plan every 6 months following the initial prescription of the CGM. | 18.83% |
3. | Medical Records or beneficiary testing logs do not meet the Glucose Monitors LCD (L33822) requirements for billing over-utilization amounts. | 18.25% |
4. | The supplier used the KX modifier incorrectly. The medical record documentation supports the beneficiary is non-insulin treated. | 4.56% |
5. | The medical record documentation does not support the beneficiary had an in-person or Medicare-approved telehealth visit with their treating practitioner to evaluate their diabetes control and determined that criteria are met within 6 months prior to ordering the continuous glucose monitor. | 4.44% |
6. | Quantity of supplies ordered is above normal allowable amounts and no medical records address the need for over-utilization. Medical records and a test log or narrative by the practitioner are required to support the requirements in the 'high utilization' section of the local coverage determination. | 4.33% |
7. | The documentation does not have a valid written order. | 2.46% |
8. | The documentation is incomplete. | 1.87% |
9. | Payment for supplies billed above normal policy usage is being denied due to lack of documentation to support that they are reasonable and necessary. | 1.52% |
10. | Payment for this item is included in the allowance for another item provided at the same time. | 1.40% |
*The total percentage will be greater than 100% because some claims were denied for multiple reasons.
**The error rate included is an overall average for the supplier specific reviews as a part of the Targeted Probe and Educate program. This is not meant to be an overall error rate for the HCPCS code or policy under medical record review.
Resources:
- Blood Glucose Monitors Prepayment Edit Resources
- Continuous Glucose Monitors and Supplies Documentation Checklist
- Glucose Monitors and Supplies Documentation Checklist
- Glucose Monitors – LCD (L33822)
- Glucose Monitors – Policy Article (A52464)
- National Coverage Determination 40.2
- Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
- Supplier Manual Chapter 3 – Supplier Documentation
Updated: November 1, 2024