Business Briefs: Manufacturers Provide Reimbursement Reminders to Podiatrists and Wound Departments

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  When Today’s Wound Clinic editors, Dr. Caroline Fife and Dot Weir, revealed that the August 2010 issue would focus on podiatrists and hospital-owned wound departments, they asked if I would interview several of the manufacturers of 1) equipment used for lower extremity studies and, 2) biomaterials used for chronic non-healing wounds. A special thank you goes out to the manufacturers who were willing to share their reimbursement reminders that are displayed in Table I and Table II. Even though the products represented span from diagnostics to advanced wound management technologies, all of the manufacturers focused on similar reimbursement issues.

Reimbursement Reminder: Use ABNs

  Many of the manufacturers’ reimbursement issues centered on the Local Coverage Determinations (LCDs) that are written by the Medicare contractors who process claims for services provided to Medicare beneficiaries. Providers must know how to locate, read, and follow the guidelines provided in the LCDs. Dr. Fife’s article and the extremity study manufacturers highlighted that some of the LCDs do not cover all the indications that appear to clinically warrant these studies and do not cover the work when performed by specially trained non-physician personnel. Some providers may believe that they cannot perform clinically appropriate extremity studies for Medicare beneficiaries if their Medicare contractor’s LCD does not cover the indication. Actually, providers can and should involve the patient in deciding if they want and will pay for a needed study, procedure, service, or product that is not covered by Medicare. This is accomplished by providing the patient with an Advanced Beneficiary Notice of Noncoverage (ABN). (See the In Business column in the January/February 2009 issue of Today’s Wound Clinic for a discussion of ABNs.) If the patient reads the ABN and chooses to accept and personally pay for the noncovered item, the provider can proceed. If the patient chooses not to accept the noncovered item, the provider then must decide if an acceptable alternative is available; the provider can choose if she/he can accept the liability for caring for the patient who has refused needed care.

Reimbursement Reminder: Use the Reconsideration Process

  Providers can also take a proactive approach to LCDs that 1) do not cover indications that are clinically appropriate, and 2) have utilizations parameters that are inconsistent with FDA labeling, clinical trials, clinical guidelines, specialty credentials, etc. This can be accomplished by making their voices heard through the Reconsideration Process (See the In Business column in the March/April 2009 issue of Today’s Wound Clinic for a discussion of LCDs and the Reconsideration Process). Providers can 1) personally submit the Reconsideration Process document, 2) invite other colleagues, their professional medical society, and beneficiaries to submit similar requests, and 3) solicit the assistance of their state medical professional society representative to the Medicare contractor’s Carrier Advisory Committee (CAC) – providers should call their state societies to learn the identity and contact information for their CAC representatives.

  Each Medicare contractor is required to describe the Reconsideration Process on their web site – to obtain this information, providers should enter “Reconsideration Process” in the search portion of their contractor’s web site. Following are some general Reconsideration Process guidelines:
    • Submit a written request that identifies the language that should be added or deleted from the LCD
    • Include justification supported by new published evidence
    • Include copies of the strongest published evidence available. In order of preference, the reconsideration request will be based on:
      º Published authoritative evidence derived from definitive, randomized clinical trials or other definitive studies
      º General acceptance by the medical community (standard of practice) as supported by sound evidence based on:
        • Scientific data or research studies published in peer-reviewed medical journals
        • Consensus of expert medical opinion ( i.e., recognized authorities in the field)
        • Medical opinion derived from consultations with medical associations or other health care experts.

  NOTE: Acceptance by individual health care providers, or even a limited group of health care providers, normally does not indicate general acceptance by the medical community. Abstracts of papers, presentations at scientific meetings, testimonials indicating limited acceptance, and limited case studies distributed by sponsors with financial interest in the outcome are not sufficient evidence of general acceptance by the medical community. Some contractor medical directors will give greater weight to studies also included in a clinical trials registry, such as ClinicalTrials.gov. Inclusion in a primary registry that meets the criteria of the International Committee of Medical Journal Editors is of particular value.

   • Address two questions:
      º Is the evidence concerning effectiveness in the Medicare population adequate to draw conclusions about magnitude of effectiveness relative to other items or services?
      º How does the magnitude of effectiveness of the new medical item or service compare to other available interventions?

  NOTE: Most Medicare contractors describe how they like to see the evidence presented – be sure to read their guidelines.

  Medicare contractors can only accept Reconsideration Process requests for LCDs published in final form. They cannot accept Reconsideration Process requests for other documents:
    • National Coverage Determinations (NCDs)
      º If modification of the LCD would conflict with an NCD, the request would not be valid. Information on how to make requests for NCD reconsiderations can be found at https://www.cms.gov/DeterminationProcess/02_howtorequestanNCD.asp
    • Coverage provisions in interpretive manuals
    • Draft LCDs   • Template LCDs, unless or until they are adopted
    • Retired LCDs
    • Individual claim determinations
    • Bulletins, articles and training materials
    • Any instance in which no LCD exists (i.e., requests for development of an LCD)

  Medicare requires the Medical contractors to follow this timeline once they receive a Reconsideration Process request:
   • Within 30 days of the day the request is received, the contractor must determine if the request is valid, based on the requirements described on their Web Site. If the request is invalid, the requester will receive a written notification that explains why the request was invalid. If the request is valid, the reconsideration process will continue.
    • Within 90 days of the day the request is received, a final LCD reconsideration decision will be made, and the requester will be notified of the decision and its rationale. Decision options include retiring the policy, no revision, revision to a more restrictive policy or revision to a less restrictive policy. If the decision is made to revise the LCD, the normal process for LCD development will be followed (see “LCD Development Process” on the Medicare contractor’s Web site).

Reimbursement Reminder: Use National Correct Coding Initiative and Outpatient Code Editor Edit Tables

  In Peggy Dotson’s article entitled Reimbursement for Total Contact Casting [www.today’swoundclinic.com-TCC-Reimbursement], she discussed how some payers will not pay the outpatient wound care department and/or the physician when they apply the total contact cast (29445) after they perform an excisional debridement or apply a biomaterial to a chronic wound that also requires a total contact cast. The same situation exists when Unna boots (29580) or multi-layer venous wound compression systems (29581) are applied after these same procedures.

 The Medicare contractors’ LCDs are not causing these payment denials. In this case, the Centers for Medicare & Medicaid Services (CMS) developed the National Correct Coding Initiative (NCCI) edit tables to promote correct coding and to control improper coding leading to inappropriate payment in Part B claims. A subset of NCCI edit tables is incorporated into the Outpatient Code Editor (OCE) tables for hospital outpatient departments such as hospital-owned outpatient wound care departments. The NCCI edit tables can be viewed at: https://www.cms.gov/NationalCorrectCodInitEd/NCCIEP/list.asp#TopOfPage. The OCE tables can be viewed at: https://www.cms.gov/NationalCorrectCodInitEd/NCCIEHOPPS/list.asp#TopOfPage.

  The main purpose of the NCCI/OCE edits is to prevent improper payment when incorrect code combinations are reported. The NCCI and OCE contain three tables of edits that include code pairs that should not be reported together for a number of reasons:

    • Mutually Exclusive Edits
      o Include codes that cannot reasonably be performed in the same session

    • Medically Unlikely Edits (MUEs)
      º Developed to reduce the paid claims error rate for Part B claims by listing the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service. NOTE: MUEs are not listed for all HCPCS/CPT®¹ codes. The MUE edits can be viewed at: https://www.cms.gov/NationalCorrectCodInitEd/08_MUE.asp#TopOfPage. NOTE: Some MUE values are confidential and are for CMS and CMS contractors’ use only: they are not listed on the published MUE edit table.

  If providers have concerns about specific NCCI/OCE edits, they should submit written requests for changes to CMS Providers may also wish to enlist other providers, their national professional medical societies, etc. to submit similar written change requests. The NCCI and OCE edits are updated on a quarterly basis. Providers should take advantage of the quarterly updates to educate CMS “why” certain procedures should be removed or added to the NCCI/OCE edit tables. Send your written requests for NCCI and OCE changes to:
  National Correct Coding Initiative
  Correct Coding Solutions LLC
  P.O. Box 907
  Carmel, IN 46082-0907
  Attention: Niles R. Rosen, M.D., Medical Director and Linda S. Dietz, RHIA, CCS, CCS-P, Coding Specialist
  Fax #: 317-571-1745

Summary

  The manufacturers and this author encourage you to 1) use ABNs when Medicare beneficiaries need non-covered services, 2) monitor all pertinent LCDs and use the Reconsideration Process to seek refinements to LCDs, and 3) monitor quarterly updates to the NCCI and OCE edit tables and submit requests for changes that are warranted. Make your professional voices heard to the payers. Remember, the payers want to hear from medical professionals. Don’t make the mistake of thinking that the manufacturers of the products can solve these reimbursement issues. The time for providers to get involved in reimbursement issues is NOW!

  Kathleen D. Schaum, MS, is 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.

1. CPT is a registered trademark of the American Medical Association