Widespread Targeted Review Results – FI - Skilled Nursing Facilities (SNFs) Billing 82962

Part A Medical Review has recently completed the 1st Quarter widespread targeted prepay review of SNFs billing of Current Procedural Terminology (CPT) 82962 (glucose, blood by glucose monitoring device(s), cleared by the FDA specifically for home use) processed January 1, 2008 through March 31, 2008.  Educational articles providing the results of previous reviews and guidelines for the appropriate utilization of blood glucose monitoring were posted on What’s New from Cahaba Web pages on December 15, 2005, February 8, 2007, May 2, 2007, July 25, 2007, October 24, 2007, and March 3, 2008. 

The results of the current review are as follows:

Providers Reviewed 3
Claims Reviewed 10
Claims Approved 0
Claims Denied 10
Charges Reviewed $3,421.47
Charges Approved $65.00
Charges Denied $3,356.47
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):  Half of the denials occurred because 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 in response to an Additional Development Request (ADR) (denial reason 56900):  Claims were denied due to a lack of record submission in a timely manner.  According to the Medicare Program Integrity Manual, (CMS Pub. 100-08), Ch. 3, Globe to indicate www link. § 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 ADR and must notify the provider of the 30 day time-period to respond.  If the ADR requested information is not received within 45 days after the date of the request, the claim must be denied. 

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

  • Effective January 1, 2007 Cahaba stopped sending letters informing providers of 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.

Refer to the Inquiry Menu section of the Fiscal Intermediary Standard System (FISS) Reference Guide for detailed information on how to access ADRs.

As a result of this probe review, Part A Medical Review will continue the 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 Globe to indicate www link. , the Medicare Benefit Policy Manual (CMS Pub. 100-02, Ch. 15, Globe to indicate www link. § 80.1, and Medicare Claims Processing Manual (CMS Pub. 100-04, Ch. 7, Globe to indicate www link. § 90.1, to ensure adherence to all coverage criteria.

Page last updated: May 21, 2008

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