DEPARTMENT  OF HEALTH  & HUMAN  SERVICES  Office of Inspector  General 
Memorandum 

MAYI4  1999 
Date 
JuneGibbsBrown 

Inspector Gener 

Medicare CoverP  of GlucoseMonitoring Performedin Nursing Homes 

Subject 
(OEI-05-99-00380) 

To  Nancy-Ann MinDeParle 

Administrator 

Health CareFinancing Administration 

  The purpose of this memorandumis to recommendthat the Health Care Financing 

Administration (HCFA) institute a national policy stipulating that daily routine glucosetesting 

servicesprovided by nursing homesareroutine careservicescoveredunder the per diem rate 

and not billable separatelyto the Medicare program. 

Historically, residential nursing facilities havenot attemptedto submit claims to Medicare for 

reimbursementfor blood glucosetestsperformed by their staff  Beginning in 1998, some 

nursing homesbegansubmitting claimsfor glucosereimbursementto Medicare fiscal 

intermediaries. Nursing homesare being advisedby a consultantthat they are ableto bill 

Medicare for glucose servicesprovided to patientsfrom asfar back as 1992. The.HCFA has 

1eRthe decision asto whether to cover theseteststo individual intermediaries. 

During the typical glucosetest in a nursinghome,.thepatients finger is pricked with a lancet 

and a drop of blood collected on a reagenttest strip. The test strip is then inserted into a blood 

glucosemonitor approvedby the Food andDrug Administration,(FDA) for home use. The 
monitors measureglucose (sugar) concentrationsby readingthe color changesproduced by the 
speciallytreated reagentstrips. 
Millions of Americans perform this test eachday in their own homes. Some patients check 
their blood glucoselevel before or after eachmeal. The FDA-approved glucose monitoring 
devices,lancetsand reagentstrips can be purchasedover the counter at most pharmaciesand 
other outlets. Medicare paysfor the monitor andtesting suppliesasdurable medical 
equipmentand suppliesfor diabetic beneficiarieswho self-test,but Medicare doesnot pay for 
the glucoseresults produced by suchequipmentunlessthe test is: 
t  Medically necessary,   

b  Ordered by a physicianandusedin the diagnosisand treatment of a patient, 

and,
b  Performed at a laboratory site having either a certificate of waiver or certificate 
of registration asrequired by the Clinical Laboratory Improvement Act.  Page2 -Nancy-Ann Min DeParle 
Many nursing homeshold a certificate of waiver. This certificate allows a nursing home to 
perform waived tests using equipment certified by FDA for home use. Waived tests are 
simple to perform and havean insignificant risk of error. They also poseno reasonableharm 
to the patient ifperformed  incorrectly. Nearly all of the glucosetestsperformed by nursing 
home personnelarewaived tests. 
. 	 Examination of Medicare payment data indicatesthat in 1996Medicare nursing homesbilled 
about $69,829 for glucosetesting: $36,010 for blood glucosetestsperhormedusing a reagent 
strip  (HCFA Common ProcedureCode 82948) and $33,819for blood glucosetests 
performed by monitoring devices (HCFA Common ProcedureCode 82962). Random   
processingerrors or a single contractors coveragepolicy might accountfor all of the 1996 
payments. Bills from nursing homesfor thesesameglucosetestsin 1998 totaled $451,507. In 
contrast, a single Medicare intermediary receivedmore than 9,000 claims for nursing home 
glucosetesting in late 1998 and early 1999. This intermediaryhaschosennot to pay the 
claims. Ifpaid,  theseclaims could cost Medicare between$3 and $4 million.  However, 
anotherfiscal intermediary is processingandwill pay many of the 2,000 claims for glucose 
testing submitted by nursing homes. Paymentsrangefrom $100 to $300 per claim. According 
to HCFA staff, nursing homeshavesubmitted more than 75,000 claims for glucose 
reimbursement. Many of theseclaims seekretroactive paymentfor 12 or more months of
* -
testing.  . 
Medicare policy doesnot speCificallyaddressglucosetesting performed by nursing homes. 
Historically, nursing homeshavenot billed Medicare for theseservices. Medicare, Medicaid 
and facilities assumedthat payment for glucosetestsperformedin acute carehospitals, SNFs 
and NHs was included in routine nursing care. Basedon a consultants advice, somenursing 
facilities havebegun billing Medicare for glucosetestsperCormedon their patients. What 
beganasa trickle of claims is rapidly becominga streamthat could adverselyafhect 
intermediary systemsand resourcesand potentially cost Medicaremillions of dollars annually. 
We believethat Medicare should not pay separatelyfor glucosetesting performed by nursing 
homeson a daily basis. Resultsfrom thesetestsareusually not reported to a physician for 
diagnostic or therapeutic intervention. The tests areperformedby facility staff because 
patientsresiding in nursing homesmay not be ableto perform the test themselves. 
A national policy prohibiting separatebilling would be consistentwith Medicare and Medicaid 
efforts to preventunbundling of servicesandto establishprospectivep,ayment rates. 
Permitting nursing homesto bill for blood glucosetestsinvites abuseand risks substantial 
program losses. 
We hope you will considerthis policy recommendation. Pleasedo not hesitateto call me or 
George Grob, Deputy Inspector Generalfor Evaluation andInspections,or haveyour staff call 
Mary Beth Clarke at (202) 619-2481 if you would like to discussthis issuefurther.