Ask the Board

In this exclusive column, Today’s Wound Clinic (TWC) offers our readers the chance to ask industry-related questions to our expert editorial board members. This month’s questions come from multiple sources.   Q: “How much attention should physicians pay to ICD-9-CM codes listed in Medicare Local Coverage Determinations (LCDs)?” A: By Kathleen D. Schaum, MS   This month, the TWC board received several questions regarding the ICD-9-CM codes that are listed in most Medicare LCDs. These wound care professionals asked: 1) If the physician did not use the specific ICD-9-CM codes listed in the LCD, would the service, procedure, and/or product be covered? 2) Is the sequence of ICD-9-CM codes on the claim form important? Here’s what you need to know:     1) If the Medicare Contractor provides a list of ICD-9-CM codes that are covered in the LCD, those are typically the only covered diagnoses for that service, procedure, and/or product.       • If the patient has one of the covered diagnoses, but the physician uses one of the non-specific ICD-9-CM codes, the physician may want to break that bad habit and begin using the most specific ICD-9-CM code(s) that pertain(s) to the patient.       • If the patient does not have one of the covered diagnoses, the physician should provide the patient with an Advanced Beneficiary Notice of Non-Coverage (ABN). The ABN will inform the patient: a) that the service, procedure, and/or product will most likely not be covered by Medicare and b) about the cost that the patient will incur to receive the non-covered service, procedure, and/or product. The patient will then have the choice of denying or accepting/paying for the service, procedure, and/or product.     2) If the LCD states the expected sequence of covered ICD-9-CM codes, the diagnosis codes should be listed on the claim form in that sequence. For example: One physician was upset that her claim for application of a cellular- and/or tissue-based product for wounds was denied for a diabetic foot ulcer. The physician knew the LCD listed the exact ICD-9-CM codes that were on the claim form. Unfortunately, the LCD stated the ulcer ICD-9-CM code was to be listed as the primary diagnosis and the diabetes ICD-9-CM code was to be listed as the secondary diagnosis. You guessed it, the physician’s claim form listed diabetes as the primary diagnosis and the ulcer as the secondary diagnosis! The claim was denied because the procedure and product is not a treatment for diabetes — they are treatments for an ulcer that is a result of diabetes. Some LCDs also describe ICD-9-CM codes that must be used in pairs. Wound care professionals should pay close attention to the required code pairs. These code pairs must be documented in the medical record by the physician and must be placed in the correct sequence on the claim form in order to receive payment for the service, procedure, and/or product and to keep your payment upon an audit. Kathleen D. Schaum can be reached for questions and consultations by calling 561-964-2470 or at kathleendschaum@bellsouth.net. For a full disclaimer related to the information in this column, please refer to Business Briefs on page 6.