Business Briefs: Coding and Medicare Coverage Review

  Hospital-owned outpatient wound care departments (HOPDs) must routinely check their Medicare contractors’ websites for updates to their Local Coverage Determinations (LCDs) and Articles that pertain to the application of compression systems. All of the Medicare contractors seem to agree that CPT® code 29580 is the appropriate code to use when applying a zinc paste Unna Boot. However, there is great disparity among the Medicare contractors regarding the appropriate CPT® code for the application of multilayered, sustained, graduated high compression systems. This author reviewed all the available LCDs and Articles on this topic (see Table 1).

   (Please note: Medicare contractors may write new and/or change existing LCDs and Articles at any time. The information in Table 1 was only accurate on the day the author drafted this column. Any or all of the Medicare contractors could have released new policies while this column was awaiting publication. Therefore, providers should assign someone to monitor all pertinent changes that are released by their Medicare contractor.)

  When the HOPD program directors and physicians review the compression guidelines that pertain to them, they should ascertain the:
    • Description of product applications covered by the CPT® code 29580
    • Alternative CPT® code(s) recommended for non-zinc paste compression systems
    • Professionals who are covered to apply the various compression systems
    • Diagnoses that support medical necessity of application of the various compression systems.

  Some Medicare contractors followed the American Medical Association’s coding guidelines; some followed the American Hospital Association Coding Clinic guidelines; and others chose to discount both sets of guidelines and wrote their own opposing guidelines. If providers disagree with their Medicare contractor’s LCD, they should take advantage of Medicare’s Reconsideration Process. This is a formal process to request updates to LCDs by providing clinical evidence to the contractor’s medical director. The exact steps in the Reconsideration Process are outlined on each Medicare contractor’s website. Providers also should enlist assistance from their professional society’s representative to the Carrier Advisory Committee (CAC). The author suggests noting that the Reconsideration Process is applicable only to LCDs. It is not applicable to Articles released by the Medicare contractors. Therefore, if your Medicare contractor only wrote an Article regarding this issue, providers cannot challenge the Article. However, providers can request that their Medicare contractor create an LCD.

  Because the major problem appears to be the non-existence of a CPT® code that exactly describes the application of non-zinc paste compression bandage systems, this author interviewed Marcia Nusgart, RPh, Executive Director, Coalition of Wound Care Manufacturers and Alliance of Wound Care Stakeholders, Bethesda, Md. The goal of the interview was to receive a summary of any industry initiatives to achieve a unique CPT® code for the application of multilayered, sustained, graduated high compression systems. The following are some of the main initiatives/outcomes that Nusgart reviewed:
    • February 1999: the American Medical Association CPT® Editorial Panel voted against issuing a new CPT® code for the application of multilayered, sustained, graduated high compression system. They recommended that existing code 29580 be used with modifier -22, if appropriate, to report this procedure.
    • July 1999: CPT® Assistant confirmed the American Medical Association CPT® Editorial Panel’s February 1999 coding decision and reminded providers to include a copy of the unusual procedure report.
    • June 2005: the American Medical Association CPT® Editorial Panel postponed making a decision regarding a request for a new CPT code for sustained graduated high-moderate venous ulcer compression therapy.

  If providers support creation of a new CPT® code for the application of the non-zinc paste compression bandage systems, they should gather published peer-reviewed clinical evidence, collect real-time data that support the clinical evidence and the new CPT® code application, enlist assistance from their CAC representatives and from their professional societies, and professionally prepare a CPT® coding application that is endorsed by all disciplines that may be affected — ie, physicians (dermatologists, vascular surgeons, general surgeons, orthopedic surgeons), and podiatrists.

  Kathleen D. Schaum, MS, is President 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.

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