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Glucose Monitors & Supplies Pre-Pay Review Quarterly Status Report

Below is the analysis of claim denials for continuous blood glucose monitor HCPCS E2103, A4239 and blood glucose test strips HCPCS code A4233-A4236, A4253, A4256, A4258, A4259, and E0607 reviewed July 1 – September 30, 2024. The error rate for this quarter is 30.76%. The top 10 reasons for claim denials are as follows:

Rank Reason Percent
1. No medical record documentation was received. 43.12%
2. Medical Records and/or beneficiary testing logs do not meet the LCD requirements for billing over-utilization amounts. 23.08%
3. 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. 10.14%
4. The supplier used the KX modifier incorrectly. The medical record documentation supports the beneficiary is non-insulin treated. 3.85%
5. The documentation does not have a valid order. 3.26%
6. 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 CGM. 2.56%
7. Payment for supplies billed above normal policy usage is being denied due to lack of documentation to support that they are reasonable and necessary. 1.98%
8. The medical record documentation does not support the beneficiary has diabetes. 1.98%
9. Payment for this item is included in the allowance for another item provided at the same time. 1.98%
10. Quantity of supplies ordered is above normal allowable amounts and no medical records were sent in to address the need for over-utilization.  Medicare requires medical records and a test log or narrative by the practitioner to support the requirements in the ‘high utilization’ section of the LCD. 1.75%

*The total percentage will be greater than 100% because some claims 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:

Updated: November 5, 2024

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