Bypass manual review requirement for medically necessary insulin pumps

As stated in a May 2020 Record article, health care providers must append the KX and TW modifiers to avoid the manual review process for a medically necessary replacement insulin pump. 

To avoid the manual review process, all the following must apply:

• Insulin pump malfunctioned.
• Manufacturer’s warranty has expired.
• Blue Cross Blue Shield of Michigan’s five-year reasonable useful lifetime, or RUL, hasn’t been reached.
• The above criteria are clearly documented in the beneficiary’s medical record.

By appending the KX and TW modifiers, you are certifying that the member’s insulin pump has malfunctioned after the manufacturer’s warranty period, but before the five-year RUL, and that the member meets Blue Cross medical criteria for an insulin pump. The KX or TW modifier can only be added to the claim if the malfunction is documented in the patient’s medical record.

As a reminder, the medical record isn’t limited to the treating practitioner’s office records, but may include records from hospitals, nursing facilities, home health agencies or other health care professionals. Records from suppliers or health care professionals with a financial interest in the claim outcome aren’t considered sufficient by themselves to determine that an item is reasonable and necessary.

Durable medical equipment prosthetic and orthotic suppliers are reminded that:

• Supplier-produced records, even if signed by the treating practitioner, and attestation letters (for example, letters of medical necessity) aren’t considered to be part of a medical record for Medicare payment purposes.
• Templates and forms, including Centers for Medicare & Medicaid Services certificates of medical necessity with a date of service before Jan. 1, 2023, must be corroborated with information in the medical record.
• A prescription isn’t considered to be part of the medical record. Medical information intended to demonstrate compliance with coverage criteria may be included on the prescription but must be corroborated by information in the medical record.
• The beneficiary’s medical record must contain sufficient documentation of his or her medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement (if applicable). The information should include the beneficiary’s diagnosis and other pertinent information including, but not limited to, duration of the beneficiary’s condition, clinical course (worsening or improvement), prognosis, nature and extent of functional limitations, other therapeutic interventions and results, and past experience with related items.