License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

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POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

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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 between April 1 and June 30, 2024. The error rate for this quarter is 31.98%. The top ten reasons for claim denials are as follows:

Rank	Reason	Percent
1.	We did not receive any medical record documentation.	33.98%
2.	Medical Records and/or beneficiary testing logs do not meet the LCD requirements for billing over-utilization amounts.	23.77%
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 six months following the initial prescription of the CGM.	18.49%
4.	The KX modifier was incorrectly appended. The medical record documentation supports the beneficiary is not insulin treated.	3.35%
5.	The documentation does not have a valid Standard Written Order (SWO).	3.26%
6.	Payment for this item is included in the allowance for another item provided at the same time.	2.73%
7.	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 six months prior to ordering the CGM.	2.38%
8.	Payment for supplies billed above normal policy usage is being denied due to lack of documentation to support that they are reasonable and necessary.	2.02%
9.	Quantity of supplies ordered is above normal allowable amounts and no medical records were sent in to address the need for over-utilization. Medical records and a test log or narrative by the practitioner must support the requirements in the ‘high utilization' section of the LCD.	1.50%
10.	The medical record documentation does not support the beneficiary has diabetes.	1.50%

*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 31, 2024

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

AMA Disclaimer of Warranties and Liabilities.

CMS Disclaimer

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

Glucose Monitors & Supplies Pre-Pay Review Quarterly Status Report

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