Blood Glucose

Wisconsin Physicians Service (WPS) Medical Review (MR) is providing this article to update providers on the status of service specific prepay edits. MR service-specific complex review edits are commonly known as prepay edits. These prepay edits suspend claims from multiple providers when a claim is submitted for payment which includes specific coding criteria for that service.

WPS MR prepay edits are continually reviewed based on reviewed claim data. Edits are modified or terminated as data analysis supports decreased vulnerability to the Medicare Trust Fund and/or workload analysis.

The following MR service specific prepay edit in the MAC J5 region is active:

Applies to the States of: Iowa, Kansas, Missouri, and Nebraska
Reason Code: 50200
Date Initiated: March 31, 2007
This prepay edit is the result of: Medicare regulations

A 100% review of Blood Glucose and Glucose Quantitative Blood, Reagent Strip was initiated due to the high probability of services provided and billed not meeting medically reasonable and necessary criteria. Routine monitoring of diabetics is never covered in a Skilled Nursing Facility (SNF), whether the beneficiary is receiving covered Part A services or not.

Blood glucose testing may be reasonable and necessary in SNFs if all of the following requirements are met:

  • Services provided are as billed and are outside current ordered parameters. (Patient is symptomatic)
  • Ordered by a qualified physician or other professional. (Physician Assistant, Registered Nurse Practitioner, etc)
  • Documentation to support prompt physician notification is provided.
  • Documentation to support unstable increases/decreases in blood glucose levels is provided
  • Documentation to support non-routine medical management of blood glucose is provided

A complex medical review will be performed on each claim to determine if medical necessity has been met. Possible reasons for denial are as follows:

Page Last Updated: Monday, 02-Apr-2012 11:13:49 CDT