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Diabetes Testing Supplies, CGM and Diabetic Shoes Documentation Requirements:

Diabetes Testing Supplies, CGM and Diabetic Shoes Documentation

By Angela Breslin, BSN, R.N

Simply stated, Medicare documentation is the key to a quality driven, results achieving, compliant and successful business.  This applies to DME providers, physicians, home health agencies, long term care facilities, or any Medicare approved supplier/provider.  Most Medicare claims that are denied are denied due to issues related to Medicare documentation errors.


Medicare states that the Medicare documentation, “should be of such content and clarity as to make it abundantly clear to any third-party reviewer, the patient’s symptoms, history, physical findings, and plan of treatment…or the claim will be denied as not being medically necessary.”

Additionally, at a high level, Medicare documentation should meet all of the following expectations:

  1. All Medicare documentation should be complete, legible, signed and dated

  2. Medicare documentation is the recording of pertinent facts of and observations about an individual’s health history, including past and present illness, test results, treatment and outcomes.

  3. The Medicare documentation of each patient encounter should include: the date, the reason for the encounter, appropriate history and physical exam, review of lab results, x-ray results, other ancillary services (where appropriate) assessment, and plan of treatment

  4. If your billing codes are time based, then the Medicare documentation must clearly and accurately notate how much time was spent with the Medicare beneficiary.

  5. If your billing for E/M services, you need to be sure that your Medicare documentation includes History of Present illness (HPI), Review of Symptoms (ROS), and Past Medical, Family, and Social History (PFSH)

  6. Your Medicare documentation should clearly and accurately include the proper ICD-10’s that are required for treatment, testing, and payment

  7. Your modifiers, if appropriate, should reflect what story the Medicare documentation tells

Medical Records Documentation Requirements: Glucose Monitoring and Test Strip Supplies

1. Dispensing Order, if applicable- Verbal Order

2. Doctors Written order- DWO

3. The Medical Records MUST state the following:

a. Medicare beneficiary has diabetes; AND,

b. Medicare beneficiary has been using a BGM and testing 4 or more times per day; AND,

c. Medicare beneficiary is insulin treated with three or more daily injections of insulin, or is treated by a Medicare approved insulin pump; AND,

d. Beneficiary’s insulin treating regime requires frequent adjustments by the beneficiary on the basis of BGM or CGM testing results; AND

e. An in-person diabetic evaluation within 6-months of ordering the CGM to determine and document that the above criteria are met; AND

f. A subsequent in-person evaluation every 6 months to verify and document daily use of CGM and assess adherence to the diabetes treatment plan.


It is important to note that all of the above medical record requirements MUST be documented in the beneficiaries actual medical records file and not simply on a supplier provided form. Far too many suppliers have been misled that simply checking a box on a form will meet the Medicare documentation requirements or be compliant with Medicare documentation requirements.  It should be noted, and understood, that if the DWO is provided by the supplier, it is not considered a part of the medical records requirements for Medicare.


In order to be compliant with Medicare documentation requirements, the Medical Records Documentation Requirements noted in this article MUST be in the medical records and be signed and dated by the health care professional who is treating the beneficiary.

According to recent Medicare TPE audit results, click here for the actual article, the following are the top Medicare TPE audit denial reasons regarding Blood Glucose Monitors:  The overall denial rate was 53%

1. Medical documentation was not received in response to the ADR letter

2. Medical documentation for Diabetic CGM and Testing supplies did not support over utilization

3. The DWO was incomplete or missing requirement elements

Medical Records Documentation Requirements: Diabetic Therapy Shoes


HCPC CODES: A5500 and A5512


In addition to the medical documentation requirements for Blood Glucose Monitors, Diabetic Therapy Shows also have the following medical documentation requirements for Medicare:

1. Signed and dated Certifying Physician Statement that meets all the medical documentation requirements below:

a. Signed by an M.D or D.O; and

b. Medicare beneficiary has diabetes; and

c. Medicare beneficiary has one of the following conditions:

1. Previous amputation of the other foot, or part of either foot, OR

2. History of previous foot ulcerations of either foot, OR

3. History of pre-ulcerative calluses of either foot; OR

4. Peripheral neuropathy with evidence of callus formation of either foot; OR

5. Foot deformity of either foot, OR

6. Poor circulation in either foot; 

d. Medicare beneficiary is being treated under a comprehensive plan of care for his/her diabetes

2. The certification statement was signed on or after the date of the in person visit AND within three months prior to the delivery of the diabetic shoes/diabetic inserts

3. Clinical evaluation documenting the management of the patient’s diabetes

a. Evaluation as performed by the certifying physician; AND

b. Visit occurred within six months prior to delivery

c. Clinical evaluation documents, in the medical records, that the beneficiary has one or more of the qualifying conditions i-vi, listed above

4. The Supplier must complete and document an in-person fitting evaluation at the time of delivery

In a recent Medicare TPE audit results article 49% of all claims reviewed in the Medicare TPE audit process were denied.  The top two denial reasons are as follows:


1. The Medical documentation was not received in response to an ADR letter

2. The medical documentation did not meet the requirements for Medicare Documentation compliance.


Being compliant with Medicare medical documentation requires is paramount to achieving operational and financial excellence.  If you receive a Medicare audit notification letter regarding a TPE audit, RAC audit, or UPIC audit, you must be diligent, complete, and timely in your response.  If you have any questions whatsoever feel free to contact Boost Advisory Group for a free consultation. Boost Advisory Group provides a 100% satisfaction guarantee regarding Medicare audit response services and Medicare documentation compliance.



About the author:

Angela M. Breslin is a Registered Nurse (BSN, RN) and the President of Boost Advisory Group. Angela has some 20+ years of clinical experience in a hospital setting. Angela is an expert in Medicare documentation compliance, Medicare, Medicaid, third party payor audits response services, appeals submissions, Medicare audits, and Medicare LCD compliance.  Angela has effectively responded to and won audit response and payer appeals across many product s and services, including but not limited to, urological supplies, wound care and surgical supplies, ostomy supplies, diabetes testing supplies, Continuous Glucose Monitors (CGM), insulin pump therapy, diabetic shoes, psychiatry, orthoses, breast pump supplies, and emergency services.


RESOURCES & LINKS:

Medicare Documentation Checklist:

Diabetic CGM & Testing Supplies Documentation Checklist

Diabetic Shoes Documentation Checklist

Medicare LCD:

Diabetic CGM & Testing Supplies LCD

Diabetic Shoes LCD

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