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DEPARTMENTS: PAYMENT STRATEGIES

Keep Your Eye on Coverage!

Schaum, Kathleen D. MS

Author Information
Advances in Skin & Wound Care: May 2021 - Volume 34 - Issue 5 - p 232-234
doi: 10.1097/01.ASW.0000742308.69803.14
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At least once a week, this author receives calls from wound/ulcer management professionals about denied Medicare claims, failed Medicare audits, and/or repayments to their Medicare Administrative Contractors (MACs). The recurring underlying reason for a large portion of these revenue losses is that medical decision-making, documentation, and coding did not align with the MAC’s Local Coverage Determinations (LCDs) and/or Local Coverage Articles (LCAs). This month’s column lists some of the wound/ulcer management coverage guidelines that physicians, other qualified healthcare professionals (QHPs), hospital-owned outpatient wound/ulcer management provider-based departments (PBDs), and durable medical equipment (DME) suppliers did not realize existed. As you read this article, highlight any pertinent Medicare LCDs and/or LCAs that are unfamiliar to you. Then, at your earliest convenience, visit your MAC’s website or the newly revised Medicare Coverage Database (www.cms.gov/medicare-coverage-database/new-search/search.aspx) to review them. While you are visiting these websites, you may also want to review some of the older LCDs and/or LCAs to refresh your memory. Following is an abbreviated list of the specific coverage problems those consulting with this author have encountered.

  • Physicians, QHPs, and/or PBDs followed National Coverage Determinations (NCDs) but did not know about or follow their MAC’s LCD and LCA on the same topic.

This author was surprised to learn that many stakeholders were only following NCDs. They thought that their MACs could not release LCDs and LCAs on the same topic as the NCD. Although it is true that MACs are not permitted to create LCDs and LCAs that are less stringent than NCDs, they can create LCDs and LCAs that have more utilization, documentation, and coding guidelines than the NCDs. If you are following an NCD, take the time to read your MAC’s LCD and LCA (where applicable) that pertain to the same topic.

  • Physicians, QHPs, PBDs, and DME suppliers did not have a process for monitoring their MAC’s coverage changes.

Many of the revenue losses reported to this author were the direct result of stakeholders following outdated LCDs and/or LCAs. The stakeholders did not realize that their MACs could retire existing LCDs and LCAs and could release new or revised LCDs and LCAs at any time and as often as the MAC has the need to clarify coverage. Therefore, this author encouraged the stakeholders to establish a process to monitor their MAC’s coverage changes monthly and share pertinent changes with their clinicians, coders, and billers. See Table 1 for a partial list of wound/ulcer management-pertinent LCDs that were revised within the last year and missed by the stakeholders who contacted this author. If your MAC is listed in the table, you should read the revised LCDs and LCAs. Further, readers should note two recently retired LCDs: L36504 (MAC, First Coast Service Options, Inc) and L35021 (MAC, Novitas Solutions, Inc), both related to hyperbaric oxygen therapy and were retired on August 27, 2020.

Table 1. - RECENTLY REVISED LOCAL COVERAGE DETERMINATIONS AND ARTICLES (PARTIAL LIST)
Medicare Administrative Contractor ID Title Latest Revision Date
CGS Administrators, LLC L33821 Negative Pressure Wound Therapy Pumps 1/1/2020
L33462 Pressure Reducing Support Surfaces—Group 2 1/1/2020
L33831 Surgical Dressings 1/1/2020
A56459 Debridement Services 10/1/2020
A57193 Routine Foot Care and Debridement of Nails 10/1/2020
A56696 Wound Application of Cellular and/or Tissue Based Products (CTPs), Lower Extremities 10/8/2020
A56697 Non-Invasive Vascular Studies 11/1/2020
A57067 Outpatient Physical and Occupational Therapy Services 1/1/2021
First Coast Service Options L37166 Wound Care 7/23/2020
A57680 Application of Skin Substitute Grafts for Treatment of DFU and VLU of Lower Extremities 8/13/2020
A57783 Incision and Drainage of Abscess of SKIN, Subcutaneous and Accessory Structures 10/1/2020
A57188 Routine Foot Care 10/1/2020
National Government Services, Inc L33631 Outpatient Physical and Occupational Therapy Services 1/1/2020
A56566 Outpatient Physical and Occupational Therapy Services 10/1/2020
A57759 Routine Foot Care and Debridement of Nails 10/1/2020
A56758 Non-Invasive Vascular Studies 2/25/2021
Noridian Healthcare Solutions, LLC L33462 Pressure Reducing Support Surfaces—Group 2 1/1/2020
L33831 Surgical Dressings 1/1/2020
A52768 High Compression Bandage System Clarification 4/29/2020
A57459/A57460 Treatment of Ulcers & Symptomatic Hyperkeratosis 6/29/2020
A57597 Routine Foot Care 1/1/2021
Novitas Solutions, Inc L35125 Wound Care 7/23/2020
A54117 Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds 8/13/2020
A52996 Routine Foot Care 10/1/2020
Palmetto GBA A53781 Spiracur Snap Wound Care System 1/1/2020
A56680 Routine Foot Care 10/1/2020
A53773/A54555 Low Frequency, Non-contact, Non-thermal Ultrasound 2/25/2021
A53065 Outpatient Physical Therapy 3/25/2021
Wisconsin Physicians Service Insurance Corporation A56232 Foot Care 11/26/2020
L37228 Wound Care 1/28/2021

  • The DME suppliers provided combinations of primary and secondary surgical dressings that did not meet LCD and LCA guidelines because the physician ordered them.

The Surgical Dressing LCD and LCA provide specific utilization guidelines for each major category of surgical dressing, for example, if a primary dressing can be changed daily, but the secondary dressing is only allowed to be changed three times per week, Medicare only covers both dressings to be changed three times per week, even though the physician may have written an order for daily dressing changes. Physicians should read the Surgical Dressing LCD and LCA to guide them in writing orders that meet the patients’ needs and that the DME suppliers can fill.

When this author questioned the DME suppliers as to why they supplied more dressings than were covered, they said they “were afraid the physicians would stop referring patients to them.” This author recommended that the DME suppliers (1) educate the physicians about the Surgical Dressing LCD and LCA and (2) remind the physicians that the DME supplier will have to present Advance Beneficiary Notices of Noncoverage to patients for dressings that exceed the maximum allowed number of covered dressings; that is, the patients will have to pay the DME supplier for those dressings that are not covered by Medicare. In most instances, physicians can find combinations of primary and secondary dressings that meet their patients’ needs and that are covered by Medicare; they just need to know the coverage guidelines.

  • Physicians, QHPs, and/or PBDs did not know that the LCDs and LCAs were revised and sometimes even relaxed.

Prior to January 1, 2020, the Surgical Dressing LCD and LCA considered alginate or other fiber gelling dressings “wound covers.” The LCD/LCA also stated that the “Use of more than one type of wound filler or more than one type of wound cover on a single wound is not considered reasonable and necessary.” As you can see, even though alginate or other fiber gelling dressings are manufactured as both primary and secondary dressings that may be used separately or together, the LCD prevented application of a primary alginate dressing covered by a secondary one.

Thanks to the efforts of the Alliance of Wound Care Stakeholders, who used the LCD Reconsideration Process (which is available for all stakeholders to use) to explain the problem to the DME MACs’ Medical Directors, the Surgical Dressing LCA was revised on January 1, 2020 (Table 1). The LCA revision now allows a primary alginate dressing to be covered by a secondary alginate dressing if appropriately ordered and documented. Unfortunately, very few wound/ulcer management professionals took advantage of the relaxed guidelines because they had not been monitoring changes in LCDs and LCAs.

  • Physicians, QHPs, and/or PBDs were not aware that the MAC that processes their claims was considering revising the coverage guidelines in existing LCDs and/or LCAs.

When MACs wish to change coverage guidelines in an existing LCD, they must release a draft LCD and provide a mechanism for all interested parties to comment in writing and open comment meetings. This is a wonderful opportunity to educate the MAC medical directors about wound/ulcer management clinical practice guidelines, published evidence, appropriate use of codes, and so on that should be considered in the coverage policy. The MAC medical directors are particularly interested in hearing from physicians/QHPs who take the time to offer their comments in a collaborative, educational manner.

Therefore, wound/ulcer management stakeholders should carefully review every draft LCD that is pertinent to their business. While reading the draft LCD, they should identify any draft coverage guidelines that do not align with accepted practice or current evidence. If stakeholders wish to have a one-on-one dialogue with the MAC medical directors who drafted the LCD, they should carefully review the comment guidelines and make the required arrangements to participate in the LCD public meeting (which can be attended virtually). On the day of the LCD public meeting, the registered presenters should (1) thank the MAC medical director for the draft guidelines that are appropriate, (2) point out the draft guidelines that are incorrect along with the reason(s), and (3) recommend language to replace the incorrect draft coverage language. See Table 2 for a few of the draft LCDs that were recently open for comments.

Table 2. - DRAFT LOCAL COVERAGE DETERMINATIONS THAT WERE OPEN FOR COMMENTS (PARTIAL LIST)
Medicare Administrative Contractor Proposed ID Proposed Title Comment Period Start Date Comment Period End Date Date of Release for Notice
Noridian Healthcare Solutions, LLC DL38902 Wound Care 1/28/2021 3/15/2021
DL38904 Wound Care 1/28/2021 3/15/2021
Palmetto GBA DL38745 Platelet Rich Plasma 9/3/2020 11/7/2020 12/24/2020

SUMMARY

This author highly recommends that wound/ulcer management stakeholders register on their MAC’s Listserv. You will then receive your MAC’s notices of coverage changes, so you can keep your eye on coverage changes that pertain to your work. By complying with coverage guidelines, you should have fewer denied claims, pass more audits, and incur fewer repayments. A little research can prevent all the heartaches, wasted time, and loss of revenue. Remember, Medicare LCDs and LCAs should be your reimbursement “playbook.”

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