MIR-2006-12A, December 2006

Edit for Blood Glucose Testing in a Skilled Nursing Facility (SNF)

Comprehensive Error Rate Testing (CERT) findings and data analysis performed by Empire Medicare Services (EMS) have demonstrated that SNFs continue to inappropriately bill for blood glucose testing. To verify coverage of this service, EMS has established an edit for blood glucose testing and will request medical records when a SNF bills for this service. The Additional Development Request (ADR) will ask the SNF to submit the following documentation to support billing blood glucose testing:

• Physician order
• Progress notes for glucose monitoring and any diabetic medical interventions
• Medication Administration Records (MAR)
• Glucose monitoring sheets for the claim period
• Nursing notes to support glucose monitoring and interventions

Coverage
Blood glucose testing is covered only in very specific circumstances and never for routine monitoring. It may be reimbursed for a beneficiary living in a skilled nursing facility under Medicare Part B (bill types 22X and 23X) when the beneficiary is not covered by Part A. Payment may be made to those providers who are registered under the Clinical Laboratory Improvement Amendments (CLIA), as well as those registered only with a certificate of waiver. The device used to perform the finger-stick blood glucose test has been added to the list of approved devices under CLIA.

SNFs may bill for blood glucose laboratory tests (finger-stick method) when the following conditions are met:

• The test is ordered by a physician/non-physician practitioner.
• The result of the test is promptly reported to the ordering physician/non-physician practitioner
• The ordering physician/non-physician practitioner uses the result in the management of the beneficiary’s specific medical needs (continuation or modification of patient care).

Repeated performance of finger-stick blood glucose tests to maintain standing orders for insulin injection does not meet the criteria listed above. The SNF may not bill for repeated laboratory services unless there is physician/non-physician involvement based on the results of the individual test.

SNFs that fail to comply with blood glucose testing regulations and continue to bill for this service when it is not appropriate to do so are subject to a referral to the Eastern Benefit Integrity Support Center (EA-BISC).

References:

• Pub. 100-04 Medicare Claims Processing Manual, Chapter 7, Section 90.1 - Glucose Monitoring
• Change Request 1362 (Glucose Monitoring)
• Change Request 1407 (Glucose Monitoring Note)
• 1861 (h) of the Social Security Act, 42 CFR 410.38

 Recent Medicare News Updates:

• 2005-11, Blood Glucose Testing in Skilled Nursing Facilities (SNF)
• 2005-10, Blood Glucose Testing in Skilled Nursing Facilities (SNF)

© All current procedural terminology (CPT) codes and descriptors copyrighted by the American Medical Association.