ReaDME News: Urological Supplies are included in CGS’s Post-Pay Medical Review

CGS announced they will be conducting a complex post-pay, service-specific, medical review for urological supplies, HCPC Codes A4351; A4352; A4353; A4355 and A4316. The review was announced after an investigation into HCPC Codes A4351; A4352; A4353; A4355 and A4316, revealed Jurisdiction B’s money was a considerably higher amount than expected. Additionally the Urological policy group ranked #18 in total comprehensive error rate testing (CERT) errors.

As a reminder to suppliers, if you receive Additional Documentation Request (ADR) letters be sure to respond quickly and accurately. CGS stated they have the authority to collect this information based on the Federal Law at SSA 1833 (e) and in Federal regulation at 42 CFR 424.5(a)(6).

If suppliers neglect to send in the requested information to a Medicare contractor, they are in violation of Supplier Standard #28. Which means their claim may be denied and will be referred to the National Supplier Clearinghouse (NSC).

An official ADR letter will contain the following information:

  1. Preliminary dispensing order
  2. A valid order
  3. The patient’s medical records (supports the medical necessity for the items and the frequency of tests ordered)
  4. Documentation from the physician’s records OR the beneficiary’s records that support/verifies how often the beneficiary is testing his/her blood glucose level
  5. Itemized proof of delivery documentation
  6. Proof of beneficiary’s or caregiver’s request for refill
  7. Any other relevant documentation
  8. Advance Beneficiary Notice (submitted with other requested documentation)