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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 code E2103, A4239 and blood glucose test strips HCPCS code A4253 reviewed between April 1 and June 30, 2024. The error rate for this quarter is 30.86%. The top ten reasons for claim denials are as follows:

Rank Reason Percent
1. 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 six months following the initial prescription of the CGM. 36.18%
2. Medical Records and/or beneficiary testing logs do not meet the Glucose Monitors LCD (L33822)External Website requirements for billing over-utilization amounts. 17.68%
3. We did not receive any medical record documentation. 16.55%
4. The KX modifier was incorrectly appended. The medical record documentation supports the beneficiary is not insulin treated. 4.83%
5. The documentation does not have a valid Standard Written Order (SWO). 4.21%
6. There is not a valid handwritten or electronic signature by the author of the medical record. 4.11%
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. 3.70%
8. The medical record documentation is dated after the date of service. 1.54%
9. Payment for this item is included in the allowance for another item provided at the same time. 1.54%
10. The KS modifier was incorrectly appended. The medical record documentation supports the beneficiary is insulin treated. 1.54%

*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 July 29, 2024

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