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Expect Tighter Controls for Diabetic Supply Claims

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  • In Coding
  • June 29, 2012
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As a result of an Office of Inspector General (OIG) June 2012 report, providers and suppliers can expect increased scrutiny of high utilization claims for test strips and lancets. In response to the report, which estimates contractors overpaid as much as $271 million for these types of claims in 2007, contractors stated they have taken, or plan to take, corrective action.
Medicare Part B covers home blood-glucose test strip and lancet supplies that physicians prescribe for their diabetic patients. The National Coverage Determination (NCD) does not specify utilization guidelines and documentation requirements; however, Local Coverage Determinations (LCDs) for the four durable medical equipment Medicare administrative contractors (DME MACs) reviewed by the OIG for this report—NHIC, Corp., National Government Services, Inc., CIGNA Government Services, and Noridian Administrative Services, LLC—state that Medicare covers up to 100 test strips and 100 lancets every month for insulin-treated diabetics, and 100 test strips and 100 lancets every three months for non-insulin-treated diabetics.
Medicare considers 50 test strips as 1 unit and 100 lancets as 1 unit, so a standard claim for a patient’s monthly (or three-month) allotment of these supplies would be two units of A4253 Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips and 1 unit of A4259 Lancets, per box of 100.
For reimbursement of a claim for a quantity of test strips and/or lancets that exceeds these utilization guidelines, there must be:

  1. Documentation supporting the specific reason for the additional supplies; and
  2. Documentation in the physician’s or supplier’s records supporting the actual frequency of testing.

The physician also must have seen the patient and evaluated his or her diabetic control within six months prior to ordering the quantity of supplies in excess of the guidelines.
For complete details of the OIG review, see the June 2012 report “Medicare Contractors Lacked Controls to Prevent Millions in Improper Payments for High Utilization Claims for Home Blood-glucose Test Strips and Lancets.”

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