In a CGS article published a while back, the DME MAC contractor reminded suppliers that pharmacists are not treating practitioners and cannot sign off on the six-month in-person visits required to substantiate resupply for continuous glucose monitors (CGMs). The article is a reminder that auditors will be looking at medical records carefully when audit activity picks up.

Next Episode: Thursday, April 18, 2024

According to the local coverage determination (LCD) for glucose monitors:

“… the treating practitioner [emphasis added] must conduct an in-person or Medicare-approved telehealth visit with the beneficiary to document adherence to their CGM regimen and diabetes treatment plan …”

For benefit integrity purposes, Medicare limits treating practitioners to individuals that can order and certify DMEPOS services. That includes:

  1. Doctors of Medicine (MD)
  2. Doctors of Osteopathy (DO)
  3. Physician Assistants (PA)
  4. Clinical Nurse Specialists (CNS)
  5. Nurse Practitioners (NP)
  6. Interns
  7. Residents
  8. Fellows

An otherwise qualifying entry in the patient’s medical record affirming the patient is using their CGM and adhering to their treatment plan will not substantiate the resupply claims if a pharmacist signs it.

CMS announced its auditing contractors would focus on CGM claims and face-to-face compliance starting with service dates six months after the end of the PHE … that’s this month. We expect audit activity for CGMs and supplies will ramp up soon, so pass this reminder on to your intake personnel so they can properly assess supporting medical records before releasing applicable claims.