Home Health & Hospice Week

New policy sets out tough requirements for any patient with a Type II diabetes dx.

If your agency doesn’t have a recent HbA1c test on file when you report a diabetes diagnosis, you may have to kiss your reimbursement for that patient goodbye.

MAC Palmetto GBA implemented a new Local Coverage Determination addressing insulin injections Dec. 30 — Home Health Plans of Care: Monitoring Glucose Control in the Medicare Home Health Population with Type II Diabetes Mellitus (L35413). The LCD states best practices for caring for Type II diabetes, including:

• Consider Metformin as a first-line therapy for Medicare beneficiaries requiring medications to achieve long-term control of glucose levels — unless there is a specific contraindication to its use.
• Include documentation of the “specific structural or functional impairments, together with the related activity limitations” in the Plan of Care for patients who require a nurse to provide daily insulin injections because they are “either physically or mentally unable to self-inject insulin.” You’ll also need to document that “there is no other person who is able and willing to inject the beneficiary.” Not including these details in the POC for patients with no other skilled services “will result in a claim denial.”
• Include “the monitoring and reporting of not only intermittent capillary blood/serum glucose levels but also quarterly (and no less often than 120 days) HbA1c levels.”

The HHH Medicare Administrative Con-tractor also asks HHAs to make certain their records for diabetic patients:

1. show that patient is either physically or mentally unable to self-inject insulin and there is no other person who is able and willing to inject the patient.

2. contain the results of the most recent HbA1c.

3. contain documentation that is legible, relevant and sufficient to justify the services billed.

The LCD also requires you to report V58.67 (Long-term [current] use of insulin) for patients with Type II diabetes who are taking insulin, points out attorney and certified coder Lisa Selman-Holman with Selman-Holman & Associates, Code Pro University and CoDR — Coding Done Right in Denton, Texas.

Here’s The Kicker

While at first blush this LCD may appear to apply primarily to patients requiring a nurse to provide daily insulin injections, it will actually affect a much larger group of patients. “This LCD applies to all patients with Type II DM,” Palmetto explained in a response to comments about the LCD published in its December 2014 J11 HHH Medicare Advisory.

Bottom line: You’ll need to make certain you have a recent HbA1c whenever you list a diabetes code on a claim. This “even applies if diabetes is secondary on a therapy-only case,” Selman-Holman says