Medicare Compliance & Reimbursement

CMS' latest guidance answers questions on when to expect payment- or denials.

The most frequently asked question at federal long-term care forums lately: When can skilled nursing facilities expect payment monitoring residents' blood-glucose levels? The answer hangs in the balance, but there are steps you can take now to protect yourself.

The query has come up at the last three SNF/Long-Term Care Open Door Forums, and except to say, "our policy hasn't changed," the Centers for Medicare & Medicaid Services has given providers little guidance. Expect that to change as providers' confusion bubbles to the top.

That confusion stems from a slow reaction from Medicare contractors to grasp CMS policy, offers Elizabeth Malzahn of FR&R Health Care Consulting in Deerfield, MI. "Three years ago, we saw a surge of facilities begin to bill for blood glucose tests," Malzahn explains. "Then the FIs said, 'Well, we better take this under review.'"

The rest is history, as they say. Now many long-term care providers are wondering why their claims are suddenly meeting with denials. Here's what they need to know.

Rule number one: Most standing orders related to blood glucose monitoring are for so-called "sliding scale" tests, reminds Malzahn. Clinicians use such routine tests to adjust insulin dosage within a set range, or sliding scale. Because the tests are routine, providers typically cannot bill for the service, experts agree.
 
Test the test: Ask yourself what the intent of the test is, suggests Bet Ellis, a consultant with LarsonAllen Health Care Group in Charlotte, NC. Will a clinician submit each result to a physician within hours of receiving it? And will the physician in turn use the findings to fine-tune the patient's insulin dose? If the answers are yes, and you can document medical necessity, go ahead and bill Medicare. If not, assume the service is routine and falls under consolidated billing, advises Malzahn.

Caveat: There's some room for interpretation. "Right now, interpretation of what's routine is very much up to the intermediaries," allows Ellis. And some are more lenient than others, she says.

Any provider attempting to bill Medicare for blood glucose monitoring should seek guidance from the intermediary, she advises.

Regardless of how your FI interprets "routine" for Part B stay residents, there will not be any opportunity for reimbursement outside prospective payment system, Ellis adds.

Reminder: If a resident's high reading begs for verification, a clinician may determine a serum glucose test is warranted, reminds Ellis. In that case, you could bill the specimen collection charge for venipuncture under Medicare Part B - assuming the resident in question is not in a Part A stay.

Yet even in this case there are caveats. Make sure your documentation is sufficient to support medical necessity. Given the extra legwork involved in proper documentation, the strategy may make sense only for "high volume" providers, cautions Ellis.
 
Editor's Note: For more information, go to CMS National Coverage Determination at http://www.cms.hhs.gov/mcd/index_secttion.asp?ncd_sections=40.