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Billing for Glucose Supplies that Exceed Reasonable and Necessary Policy Parameters

The Jurisdiction B Medical Review Department continues the review of claims for glucose testing supplies for noninsulin-dependent beneficiaries. From these reviews, Medical Review has identified many instances of incorrect billing to Medicare for quantities of supplies that exceed policy parameters when coverage of the “excess” supplies is not supported by documentation within the beneficiary’s medical record.

According to the LCD, for glucose monitors (L27231), for a beneficiary who is not currently being treated with insulin injections, Medicare will cover up to 100 test strips and up to 100 lancets every three months if the basic coverage criteria are met. In order for Medicare to cover more than this amount, additional coverage criteria must be met. The justification showing these criteria are met must be evident in the beneficiary’s medical record. If the additional coverage criteria are not documented in the beneficiary’s medical record, the supplier must not submit a claim to Medicare for the purpose of obtaining Medicare payment.

When a supplier receives an order for a quantity of supplies that exceeds the reasonable and necessary parameters set forth in the medical policy and the documentation in the beneficiary’s medical record does not support the need for the quantity ordered, the supplier may collect from the beneficiary the amount for the excess quantity provided if a properly completed ABN is obtained prior to dispensing the item(s). When an ABN is executed in this situation, the excess quantity is billed as an “upgrade.”

Excess Quantities Provided/Billed as an Upgrade (ABN on File)

In order to collect from the beneficiary the difference between the reasonable and necessary quantity allowed and the excess quantity of supplies provided, the supplier must have a properly executed ABN on file. Then the supplier must submit the claim with the GA and GK modifiers as follows:

The supplier must bill the total quantity dispensed with a GA modifier on one claim line and the reasonable and necessary quantity allowed per policy with GK upgrade modifier on the following claim line. The codes must be billed in this specific order on the claim. Following is an example of a claim for glucose testing supplies for a non-insulin dependent beneficiary receiving a total of 300 test strips and 300 lancets when only 100 each is considered reasonable and necessary according to medical policy:

  • Line 1: A4253KSGA – 6 UOS – Charges associated with this line are total charges for the entire 300.
  • Line 2: A4253KSGK – 2 UOS – Charges associated with this line are for the 100 allowed per policy.
  • Line 3:  A4259KSGA – 3 UOS – Charges associated with this line are total charges for the entire 300.
  • Line 4: A4259KSGK – 1 UOS – Charge associated with this line are for the 100 allowed per policy.

When billed in this manner, the claim line with the GA modifier will be denied as not medically necessary with a PR message and the claim line with the GK modifier will continue through the usual claims processing (if the claims do not hit any other edits, i.e., eligibility edits, Medicare secondary payer edits, claims processing edits, etc.). The beneficiary will be assigned financial liability for the difference between the medically necessary amount and the amount of the excess supplies as well as any coinsurance and applicable deductible amounts associated with the medically necessary amounts.

Excess Quantities Provided/Billed as an Upgrade (No ABN on File)

If the excess quantities provided were not reasonable and necessary and the supplier did not properly execute an ABN prior to dispensing the items, the supplier submits the claim with the GZ and GK modifiers. The supplier must bill the total quantity dispensed with a GZ modifier on the first claim line and the reasonable and necessary quantity allowed per policy with GK modifier on the following claim line. (Note: The codes must be billed in this specific order on the claim.)

  • Line 1: A4253KSGZ – 6 UOS – Charges associated with this line are total charges for the entire 300.
  • Line 2: A4253KSGK – 2 UOS – Charges associated with this line are for the 100 medically necessary allowed per policy.
  • Line 3: A4259KSGZ – 3 UOS – Charges associated with this line are total charges for the entire 300.
  • Line 4: A4259KSGK – 1 UOS – Charge associated with this line are for the 100 allowed per policy.

Note: Suppliers are required to use all appropriate modifiers applicable per the LCD and any others that may apply. The examples provided do not include all modifiers that could be necessary, e.g., KL, 99, KB etc.

When a supplier receives an order for a quantity of supplies that exceeds the reasonable and necessary parameters set forth in the medical policy and the documentation in the beneficiary’s medical record does not support the need for the quantity ordered, it is recommended that the supplier alert the ordering physician that the excess quantity (dosage, frequency, usage, etc.) will not be covered by Medicare. Communication between the supplier and physician may enable the physician to provide satisfactory documentation for glucose supplies. You should reference the Dear Physician Letter: Glucose Monitors and Supplies on our website.

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