Widespread Targeted Review Results – AL - FI – 2nd Quarter 2007 Review of Medicare Skilled Nursing Facilities (SNF) Inpatient Part B Only Services (22X bill type), billing CPT 82962 (glucose, blood by glucose monitoring device(s), cleared by the FDA specifically for home use); Edit Reason Code 5121K

Alabama Medical Review Part A has recently completed the 2nd quarter widespread targeted prepay review of SNF billing of Current Procedural Terminology (CPT) 82962 (Glucose, blood by glucose monitoring device(s), cleared by the FDA specifically for home use) processed between April 1, 2007 through June 30, 2007. Educational articles providing the results of previous reviews and guidelines for the appropriate utilization of blood glucose monitoring were posted on What’s New January 2004, April 2005, and December 2005, February 2007, and April 2007. These articles may be found on the What's New from Cahaba page.

The results of the current review are as follows:

Providers included in review - 3
Claims Reviewed – 13
Claims Denied – 12
Charges Reviewed - $1,041.20
Charges Denied - $1,021.20
Error Rate: 98%*
* Error rate is based on the charges denied divided by the charges reviewed

The review decisions were based on the CMS criteria for laboratory services set forth in part in Section 1862(a)(1)(A) of the Social Security Act which requires services to be reasonable and necessary for diagnosis and treatment in order to be covered by Medicare. 42 CFR §410.32 further specifies that for a laboratory service to be reasonable and necessary, it must not only be ordered by the physician but the ordering physician must also use the result in the management of the beneficiary’s specific medical problem. Implicitly, the laboratory result must be reported to the physician promptly in order for the physician to use the result and instruct continuation or modification of patient care; this includes the physician’s order for another laboratory test.

Lack of documentation to support the medical justification for the services rendered (Denial Reason 56155): The majority of denials occurred as a result of the medical record documentation lacked the medical justification for the laboratory services as outlined in the above-cited CMS regulations. A standing order for intermittent blood glucose testing, (e.g. twice per day or once per month) and/or sliding scale insulin injections are examples of non-covered laboratory services when they do not meet the ordering physician’s utilization requirements described above. Both instances lack support of a clear use of a laboratory result prior to a similar subsequent laboratory order or use as a result’s driven intervention by the ordering physician and therefore do not qualify for separate payment under the Medicare laboratory benefit.
Lack of timely submission of requested documentation (Denial Reason 56900): Additionally, claims were denied due to a lack of record submission in a timely manner. According to The Medicare Program Integrity Manual, PUB 100-8, Chapter 3, § 3.4.1.2, if a coverage or coding determination cannot be made based upon the information on the claim, the Fiscal Intermediary (FI) may solicit additional documentation from the provider by issuing an Additional Documentation Request (ADR) and must notify the provider of the 30 day time-period to respond. The ADR requested information is not is received within 45 days after the date of the request, then the claim must be denied.

To eliminate 56900 denials, please review the following elements to ensure appropriate and timely record processing:

Beginning January 1, 2007, Cahaba will no longer send letters to inform providers of Additional Development Requests (ADRs). Instead, providers will need to access the Fiscal Intermediary Standard System (FISS) to identify claims selected for ADR. Claims selected for ADR can be identified by accessing FISS Inquiry Option 12, and will appear in status location S B6001. Pages 07 and 08 of the claim will contain the date your documentation is due, and the elements of documentation requested.
Print screen the ADR letter and attach the copy to the front of the requested medical documentation
Send requested information to the address on the ADR letter
Do NOT send certified mail or overnight mail
Include ALL requested documentation outlined in the ADR
Submit the above information via regular mail in a timeframe to ensure the FI receives the information by the 45th day after the date of the request.

As a result of this probe review, Alabama Part A Medical Review will continue the 100% targeted pre-pay review of SNFs (Bill Type 22X) billing CPT 82962, identified by edit reason code 5121K. Also, providers identified through data analysis as driving this aberrancy may warrant provider specific medical review.

In addition to the aforementioned references, SNF providers billing for laboratory services should review 42 CFR §411.15, Program Memorandum (PM) AB-00-108, Medicare Benefit Policy Manual PUB 100-2, Chapter 15, § 80.1, and Medicare Claims Processing Manual PUB 100-4, Chapter 7, § 90.1, to ensure adherence to all coverage criteria.

Page last updated: July 25, 2007