Abstract
Wound care stakeholders should remember that Medicare reimbursement requires three parts: a relevant code, a published Medicare payment rate, and positive coverage or coverage based upon medical necessity. Qualified healthcare professionals, scientists, and manufacturers should establish a monthly routine, where they personally review revisions to pertinent National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs). These documents provide specific guidelines for positive coverage by the specific Medicare Administrative Contractor that processes the Medicare claims in a specific jurisdiction. When given an opportunity to provide comments on draft coverage determinations, wound care stakeholders should take advantage of the opportunity of educating the contractor medical director. After a LCD has become active, wound care stakeholders can and should request revisions, through the LCD Reconsideration Process, when new clinical evidence becomes available.
Kathleen Dianne Schaum, MS
Introduction
Wound care professionals, scientists, and manufacturers tend to focus on coding and payment for their products, procedures, and services. Although both of those reimbursement components are important, they do not guarantee Medicare coverage. In fact, this author spends many hours each year teaching the following three concepts:
1. The existence of a CPT® (CPT is a registered trademark of the American Medical Association) code, Healthcare Procedure Coding System (HCPCS) code, and/or ICD-9-CM code does not guarantee Medicare payment.
2. The existence of a CPT® code, HCPCS code, and/or ICD-9-CM code and a published Medicare payment rate do not guarantee Medicare coverage.
3. Reimbursement requires three components: an appropriate code, a published Medicare payment rate, and coverage by the Centers for Medicare & Medicaid Services (CMS) and/or the Medicare Administrative Contractors (MACs).
Many wound care professionals take personal responsibility for learning the appropriate codes that are relevant to the services and procedures they perform and to the products they use. They also usually know the exact Medicare payment rate for each service, procedure, and product. However, they do not always take personal responsibility for monitoring and knowing Medicare's National and/or Local Coverage Determinations (NCDs and/or LCDs).1,2 The same can be said for scientists and manufacturers of wound care products and procedures: they typically focus on obtaining a code and a published Medicare payment rate for their new technology and are often blindsided by Medicare coverage determinations after their new technology is launched.
These coverage determinations are Medicare's specific rules for who, what, where, when, and why Medicare will pay for a service, procedure, and product. Just like athletes cannot play a sport without knowing the rules, wound care professionals, scientists, and manufacturers cannot successfully receive Medicare payment and/or keep their Medicare payment if they do not have first-hand knowledge of Medicare's rules of the game: NCDs and LCDs.
Discussion
Medicare coverage database
Wound care professionals, scientists, and manufacturers can begin to identify all NCDs and LCDs/Articles that are pertinent to their work by making a list of the codes that are relevant to their services, procedures, and/or products. Then they can search the Medicare Coverage Database3 for any NCDs and LCDs/Articles that pertain to those codes.
CMS has not written many NCDs that are pertinent to the wound care industry. However, those NCDs must be implemented by every MAC and must be followed by every wound care professional. Some examples of current NCDs that are pertinent to wound care can be found in Table 1.
Table 1.
Examples of National Coverage Determinations pertinent to the wound care industry
| NCD Number | NCD Title | Link to NCD CMS website (accessed July 8, 2013) |
|---|---|---|
| 270.3 | Blood-derived products for chronic nonhealing wounds | www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=217&ncdver=5&bc=AgAAgAAAAAAAAA%3d%3d& |
| 270.1 | Electrical stimulation and electromagnetic therapy for the treatment of wounds | www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=77&ncdver=2&bc=AgAAgAAAAAAAAA%3d%3d& |
| 20.29 | Hyperbaric oxygen therapy | www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=12&ncdver=3&bc=AgAAgAAAAAAAAA%3d%3d& |
| 280.6 | Pneumatic compression devices | www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=225&ncdver=1&bc=AgAAgAAAAAAAAA%3d%3d& |
| 310.1 | Routine costs in clinical trials | www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=1&ncdver=2&bc=AgAAgAAAAAAAAA%3d%3d& |
| 270.1 | Treatment of decubitus ulcers | www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=47&ncdver=1&bc=AgAAgAAAAAAAAA%3d%3d& |
NCD, National Coverage Determination; CMS, Centers for Medicare & Medicaid Services.
When a NCD does not exist, each MAC has the authority to (1) pay for a service, procedure, or product based on medical necessity documented in the medical record, or (2) write a LCD. If the MAC chooses to write a new LCD or to revise an existing LCD that provides new coverage restrictions, the MAC is required to solicit public comments about the draft LCD. Public comments can be made in writing and/or in open LCD meetings. These comment periods should be taken seriously by all wound care stakeholders; they should bring forth all clinical evidence that is necessary to provide positive coverage for the service(s), procedure(s), or product(s) that is/are the subject of the draft LCD. Some examples of current LCDs that are pertinent to wound care can be found in Table 2.
Table 2.
Examples of Local Coverage Determinations pertinent to the wound care industry
LCD, Local Coverage Determination; DME, durable medical equipment; MAC, Medicare Administrative Contractor.
LCD coverage information
Just like an athlete's playbook, an LCD contains the MAC's coverage rules. In addition, like athletic teams, every member of the healthcare team (qualified healthcare professionals, nurses, therapists, program directors, office managers, billers, coders, compliance officers, etc.) must read, understand, and follow the LCD guidelines. When reviewing an LCD, the wound care stakeholder should search for the answers to some very important questions and look in the appropriate section of the LCD—all LCDs contain identical sections.
-
• Information section of LCD
○ To what state(s) does the LCD pertain?
○ What is the effective date of this version of the LCD?
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• Indications and Limitations of Coverage and/or Medical Necessity section of LCD
○ What are the conditions under which the service, procedure, or product are covered?
○ What standards of care must be tried before the service, procedure, or product can be covered?
○ Are there any limitations to the timing, frequency, and number of services, procedures, or products that will be covered?
○ Who may perform the service or procedure and/or provide the product?
○ What are the specific indications and limitations for coverage of each service or procedure and/or product?
○ What services, procedures, and/or products are not covered?
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• Coding Information section of LCD
○ What are the bill types typically used to report the covered service, procedure, and/or product?
○ If the provider uses revenue codes on claim forms to report their services, what revenue codes did the contractor identify as acceptable for use with the CPT®/HCPCS codes included in the LCD?
○ What CPT®/HCPCS codes are covered/noncovered?
○ What ICD-9-CM codes support medical necessity for coverage?
○ What diagnoses do not support medical necessity?
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• Documentation section of LCD
○ What medical record documentation is required?
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• Utilization Guidelines section of LCD
○ How often and for how long may the service or procedure be performed?
○ How often and for how long may the product be used?
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• Related Documents section of LCD
○ Are there any attached Articles?
○ What additional coverage guidelines are provided in the attached Article(s)?
Once the LCD has been thoroughly reviewed, the wound care stakeholders should do everything possible to meet all of the coverage requirements to be properly paid.
Monthly NCD and LCD monitoring
Wound care professionals, revenue cycle staff, scientists, and manufacturers should personally monitor Medicare's coverage database on a monthly basis. Following are a few tips for establishing an LCD monitoring process:
• Make a list of all the CPT® and HCPCS codes for which you bill.
• Search for NCDs (released by CMS) and active and draft LCDs (released by the MAC that processes your claims) pertinent to the CPT® and HCPCS codes.
• Print the NCD, LCDs, and attached Articles.
• Read the NCDs and active LCDs/Articles and have a team meeting to be sure everyone understands how the changes will impact them and how they should incorporate the changes into their practice.
• Read the draft NCDs and LCDs, note the comment period deadline, and submit your comments by the deadline.
• Assign someone to, once a month, look for new drafts or revised NCD and LCDs/Articles. Repeat the steps outlined above for incorporating the guidelines into your practice and for commenting to drafts.
NOTE: If a NCD or LCD pertaining to a particular service, procedure, or product does not exist, the MAC will make a coverage decision based upon medical necessity.
Exercise your right to comment on draft NCDs and LCDs
Wound care stakeholders have the right to comment on draft NCDs and LCDs. They should exercise their right and take personal responsibility for commenting on draft coverage policies (in person at open LCD meetings and/or in writing). This is your opportunity to educate the MAC medical directors by sharing your wound care expertise with them. This author has often heard physicians say that commenting to draft coverage determinations is the manufacturers' responsibility. In actuality, the MAC medical directors prefer to hear from the qualified healthcare professionals, in their jurisdiction, who have practical experience with the service(s), procedure(s), and/or product(s) that are the subject of the draft coverage determination. Therefore, qualified healthcare professionals should carefully read the comment directions to understand the following.
• The closing date of the comment period.
• The option(s) for commenting: in-person presentation (PowerPoint, executive summary, etc.), teleconference presentation, written comments (submitted through fax, mail, e-mail).
• If an open LCD meeting is an option: date, time, address, and registration requirements.
• A teleconference presentation, date, time, call-in number, pass code, and registration requirements.
When preparing comments to the draft NCDs and LCDs, qualified healthcare professionals should support their recommendations with published clinical evidence.
Exercise your right to challenge an LCD
Once an LCD is finalized and implemented, all wound care stakeholders in that particular jurisdiction are obligated to follow the LCD. In addition, auditors who review medical records will compare the medical record to the LCD that existed on the day the service, procedure, and/or product was provided to the patient.
Therefore, wound care stakeholders should be vigilant when new clinical evidence becomes available. If that evidence proves that one or more guidelines in an LCD are no longer correct, the wound care stakeholders can request the MAC medical director to revise the whole LCD or any provision of the LCD through the LCD Reconsideration Process. Wound care stakeholders can find exact directions for the LCD Reconsideration Process on each MAC's Website.
In general, LCD Reconsideration Process requests must be submitted in writing, and must identify the language that the requestor wants added to or deleted from the LCD. Requests must include a justification supported by new evidence, which may materially affect the LCD's content or basis. Copies of published evidence included in the request must be full text articles. Most MACs will accept the request through mail, fax, or e-mail: check their individual websites for the exact contact information.
Within 30 days of receiving the LCD Reconsideration Process request, the MAC medical director will determine if the request is valid or invalid. If the request is invalid, the MAC medical director will send a written response, explaining why the request was deemed invalid, to the requestor.
If the LCD Reconsideration Process request is valid, the MAC medical director will make a final LCD reconsideration decision within 90 days of the day the request was received. The MAC medical director will notify the requestor of the decision and the rationale for the decision. The decision options include (1) retire the LCD, (2) make no revision, (3) revise the LCD to a more restrictive policy, or (4) revise the LCD to a less restrictive policy.
Abbreviations and Acronyms
- CMS
Centers for Medicare & Medicaid Services
- CPT®
Current Procedural Terminology
- HCPCS
Healthcare Procedure Coding System
- ICD-9-CM
International Classification of Diseases–9th Edition-Clinical Modification
- LCD
Local Coverage Determination
- MAC
Medicare Administrative Contractor
- NCD
National Coverage Determination
Acknowledgments and Funding Sources
No funding sources to acknowledge.
Author Disclosure and Ghostwriting
This author is the President of her own consulting firm, Kathleen D. Schaum & Associates, Inc., and is the Director of Medical Products Reimbursement for Healthpoint Biotherapeutics. This article was written by its author.
About the Author
Kathleen D. Schaum, MS, is the President and Founder of Kathleen D. Schaum & Associates, Inc., Lake Worth, FL. Ms. Schaum can be reached for questions and consultations by calling 561-964-2470 or through her email address: kathleendschaum@bellsouth.net
References
- 1.National Coverage Determinations Database. CMS website. www.cms.gov/medicare-coverage-database/indexes/national-and-local-indexes.aspx. [Jul 8;2013 ]. www.cms.gov/medicare-coverage-database/indexes/national-and-local-indexes.aspx
- 2.Local Coverage Determination Database. CMS website. www.cms.gov/medicare-coverage-database/indexes/national-and-local-indexes.aspx. [Jul 8;2013 ]. www.cms.gov/medicare-coverage-database/indexes/national-and-local-indexes.aspx
- 3.Medicare Coverage Database. CMS website. www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx. [Jul 8;2013 ]. www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx