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CMS has approved two new topics for the DMEPOS RAC, Performant, to begin reviewing, effective September 8, 2020.

Continuous Glucose Monitor: Medical Necessity and Documentation Requirements

Description: Documentation will be reviewed to determine if a therapeutic continuous glucose monitor meets coverage criteria and/or is medically reasonable and necessary.

Review Type: Complex

Affected Codes: K0554, K0553

Dates of Service: Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date and prior to July 1, 2017.

Continuous Glucose Monitor Supplies: Excessive Units

Description: More than one supply allowance for therapeutic continuous glucose monitor (CGM), including all supplies and accessories (code K0553) per 30 days is not reasonable and necessary. Units billed in excess of one will be recouped. 

Review Type: Automated

Affected Codes: K0553

Dates of Service: Claims that have a “paid claim date” which is less than 3 years prior to the Informational Letter date (automated review). Exclude from review claims prior to July 1, 2017.

Want some help? Come to the experts! 

The van Halem Group offers proactive and reactive services to assist you. If you receive an audit request from the RAC our clinical team will review the claim file and respond to the audit on your behalf. If denied, we will work with you to obtain addendums and appeal the overpayment.

Want to feel confident that the equipment you are providing meets coverage criteria? Sign up for our clinical prescreen review program.

Before you put out the equipment, let our clinical staff review your documentation to ensure the equipment meets coverage criteria. Our clinicians will review your documentation and provide you with an “approved” or “denied” status, along with recommendations for your referral source. Get your documentation right before you bill the claim to Medicare, and rest easy knowing you are protected should those claims be audited in the future.  In fact, we feel so confident in our clinical prescreen process, if you receive a denial on a claim that received vHG “approval”, we will appeal on your behalf – for free*! That is how confident we are in our  prescreen program.

Contact us for more information!

*Claim must be submitted with same documentation provided at prescreen level. Any changes or alterations void free appeal.