CGS recently alerted suppliers that patients will no longer need a change in medical necessity to switch between supply types for continuous glucose monitors (CGM) and blood glucose monitors (BGM). Instead, the contractor will accept supplier attestations to affirmatively discontinue one service if the patient intentionally switches to the other.
CMS treats BGMs and CGMs as same or similar equipment. Medicare usually pays claims after a change in condition forces patients to switch from one to the other. However, in cases where patients return to using BGMs after unsuccessful CGM use, the MACs have typically denied claims because processing logic does not contemplate patients going back down the proverbial equipment ladder. The quirk leaves suppliers with little to no recourse for payment of medically necessary supplies.
Under the revised rules, suppliers should include the following narrative to prompt DME MACs to force the switch between testing supply types in the claims processing system:
“Beneficiary discontinued CGM and switched to BGM.”
In issuing this guidance, CGS makes clear it is not changing its position that BGM and CGM equipment are same and similar. As a result, Medicare will not pay for duplicate or replacement equipment after a switch. Beneficiaries that switch between devices must utilize patient owned equipment or purchase a replacement device out-of-pocket. Should the supplier provide alternative equipment before the end of the original equipment useful life, we strongly recommend securing an ABN.
SOURCE LINKS
https://cgsmedicare.com/jc/pubs/news/2021/05/cope22121.html
CMS treats BGMs and CGMs as same or similar equipment. Medicare usually pays claims after a change in condition forces patients to switch from one to the other. However, in cases where patients return to using BGMs after unsuccessful CGM use, the MACs have typically denied claims because processing logic does not contemplate patients going back down the proverbial equipment ladder. The quirk leaves suppliers with little to no recourse for payment of medically necessary supplies.
Under the revised rules, suppliers should include the following narrative to prompt DME MACs to force the switch between testing supply types in the claims processing system:
“Beneficiary discontinued CGM and switched to BGM.”
In issuing this guidance, CGS makes clear it is not changing its position that BGM and CGM equipment are same and similar. As a result, Medicare will not pay for duplicate or replacement equipment after a switch. Beneficiaries that switch between devices must utilize patient owned equipment or purchase a replacement device out-of-pocket. Should the supplier provide alternative equipment before the end of the original equipment useful life, we strongly recommend securing an ABN.
SOURCE LINKS
https://cgsmedicare.com/jc/pubs/news/2021/05/cope22121.html
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