10.Home Glucose Monitors
Published Winter 1999
DMERC REGION C PHYSICIAN INFORMATION SHEET (PHYIS):
Revised Home Glucose Monitors Policy
Medicare, through its Durable Medical Equipment Regional Carriers (DMERCs), has been covering home glucose monitors and diabetic testing supplies for insulin-treated diabetics. In keeping with the Balanced Budget Act of 1997, coverage has now been expanded (as of July 1, 1998) to include
diabetics as well.
As physicians know, Type 1 diabetics are normally insulin-treated (and insulin dependent); Type 2 diabetics may or may not be insulin treated, depending on whether they are using oral hypoglycemics alone, are combining them with insulin, or have progressed to being solely insulin treated. This distinction is important because the revised policy distinguishes the quantity of testing supplies that should be adequate, based upon whether insulin is being used for diabetic control (which would require more frequent testing).
Because of the significant impact on the Medicare Trust Fund expected from this benefit expansion, the DMERC medical review policy has developed utilization guidelines and documentation requirements to monitor appropriate utilization of glucose monitor supplies. These requirements reflect accepted standards of care in the clinical community, and should entail no more effort on the part of physicians than would normally be expended in the monitoring of patients whose careful control of their diabetes should involve follow-up and medical record documentation commensurate with the level of testing being ordered to assure adequate control.
Basic Coverage Criteria
In order for a Medicare patient to qualify for coverage of a home glucose monitor and testing supplies, the basic necessary elements are that the patient have diabetes (ICD-9 Diagnosis codes 250.00-250.93), that the equipment and supplies are being ordered by the physician who is treating the diabetes, and that the patient or caregiver has been trained in its use and is capable of and compliant with using the obtained results to assure appropriate glycemic control, in cooperation with the physician's instructions. Additionally, the
physician is expected to renew the order for testing supplies every 6 months.
Monitors with voice synthesizers are covered for patients with bilateral best corrected visual acuity of 20/200 or worse.
Usual Quantities of Testing Supplies
The most regularly consumed supplies are the test strips and the lancets used in conjunction with the glucose monitor. If the patient meets the above basic coverage requirements the following amounts of supplies are covered depending on whether or not they are insulin treated:
Up to 100 lancets and 100 test strips every 3 months.
Up to 100 lancets and 100 test strips every 1 month.
It is important to understand that Medicare
cover quantities in excess of these amounts, but with the following additional requirements:
When Greater than the Usual Quantities are Ordered
If greater than the above amounts are required to assure appropriate glycemic control, the physician is expected to document in the patient's medical record the reasons for the higher than usual testing frequency. Because the commercial provider of these supplies is held liable for overpayments for higher quantities of supplies for which adequate documentation is lacking, it is in their interest as well as the physician's own record-keeping needs, that such documentation be performed.
Additionally, the physician must see and evaluate the patient within 6 months prior to ordering (and renewing prescriptions for) higher than usual quantities.
When higher than usual quantities of supplies are ordered, the patient may be asked by the supplier to forward a log of test results corroborating higher testing frequency. This should not prove an extra burden on the patient, since it is expected that the physician is relying on just such a log to guide ongoing therapeutic adjustments (else why are higher quantities being ordered if they are not being used for testing?)
Suppliers must receive a written order from the physician before they may submit claims to Medicare for reimbursement. The order should include an accurate ICD-9 diagnosis code, whether or not the patient is using insulin injections, and list the ordered items and frequency of testing. Orders for diabetic supplies must be renewed every 6 months.
PLEASE HELP THE SUPPLIER
It is the supplier who is financially at risk with the Medicare Program if coverage criteria and documentation requirements are not met when claims for these items are inappropriately paid. The supplier's service is essential in providing the needed equipment and supplies so that your patients can comply with your efforts to successfully treat them and prevent the devastating consequences of poorly controlled diabetes. As you can see, the above coverage criteria and documentation requirements are consistent with good standards of clinical care for diabetes, and should not present an unreasonable burden beyond what physicians should be doing anyway to assure proper care and follow-up for their diabetic patients.
Please support the supplier, who is relying upon you to comply with basic prescription renewals, and to properly document in the patient's records the reasons for higher than usual frequency of testing and confirmation of office visits, as may be requested by the supplier.
Medicare Program Viability
This Medicare benefit for diabetics has been greatly expanded to include the millions of non-insulin treated diabetics, consistent with current standards of practice. Please help the DMERCs to administer this benefit in a rational manner; every effort has been made to minimize coverage and documentation requirements in order to assure only medically necessary utilization and costs to the Medicare Program, while still facilitating the ordering, dispensing and reimbursement of necessary items that will benefit our elderly patients. The less funds Medicare loses to fraudulent and abusive supply "utilization," the more there are available for other benefits and program costs (including physician services).
This physician information sheet was originally published in the
DMERC Medicare Advisory.
Paul D. Metzger, M.D.
Medical Director, Region C DMERC
2002, Palmetto GBA. All Rights Reserved.