Understanding what Medicare expects when ordering diabetes supplies

Sometimes, it’s not about getting paid. Sometimes, it’s about getting your patients what they need with the least amount of hassle and paying yourself with the time saved.

One of the ongoing sources of frustration for family physicians is helping their Medicare patients with diabetes receive the testing supplies they need to help manage their condition. Physicians have to continually order refills even though they know the patients will need to test for the rest of their lives and have to specify the brand name of the products they are ordering even though, from a clinical standpoint, the name of the brand doesn’t matter. Apparently, “diabetic testing supplies” is inadequate for Medicare purposes.

So, what do the Medicare administrative contractors (MACs) that process claims for glucose monitors and related supplies (e.g. lancets and test strips) expect from physicians? One of the MACs recently attempted to address that question.

For glucose monitors, Medicare requires the following prior to delivery by a supplier:

•    A face-to-face visit with the prescribing practitioner within six months before prescribing, including documentation that the patient was evaluated, treated or both for diabetes mellitus supporting need for the glucose monitor ordered,
•    An order that includes:
     o    Patient name
     o    Item ordered
     o    National Provider Identifier
     o    Date of the order
     o    Prescribing practitioner signature

Other diabetes testing supplies, such as test strips and lancets, require a detailed written order to the supplier. The detailed written order must contain:

•    Beneficiary's name
•    Prescribing practitioner’s name
•    Date of the order
•    Detailed description of the item(s)
•    Frequency of use or testing
•    Quantity to be dispensed
•    Number of refills
•    Prescribing practitioner’s signature and signature date

Be aware that there are limits to the quantity of test strips and lancets that Medicare covers when the basic coverage criteria are met. For beneficiaries treated with insulin, this limit is 300 every three months. For beneficiaries not receiving insulin, the limit is 100 every three months.

Medicare will cover quantities above these limits, but you have to document additional criteria in your patient’s medical record and be prepared to make that documentation available upon request. These additional documentation requirements are that you have seen and evaluated the beneficiary’s diabetes within six months of ordering supplies in excess of the normal amounts and have documented in the medical record the specific reason for the additional supplies. Also, you need:

•    Medical records documenting frequency of actual testing by beneficiary;
•    Specific narrative that documents frequency beneficiary is actually testing; or
•    Copy of the beneficiary’s testing log (must be provided to physician by beneficiary).

This guidance will not solve all of the hassles associated with getting your Medicare patients with diabetes the testing supplies they need. However, if it helps you get your patients the items they need faster, then so much the better for you, them, and Medicare.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians