Business Briefs: DME Medicare Administrative Contractor LCDs Are Important to Qualified Healthcare Professionals Specializing in Wound Care

Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure the accuracy of the information. However, HMP Communications and the authors do not represent, guarantee, or warranty that the coding, coverage, and payment information is error-free and/or that payment will be received. The ultimate responsibility for verifying coding, coverage, and payment information accuracy lies with the reader.   Ever since this column began, we have repeatedly discussed the reimbursement importance of monitoring, reading, and integrating your Medicare Administrative Contractor’s (MAC) Local Coverage Determinations (LCDs) into your wound care services. However, we have not spent much time discussing how documentation and written orders affect reimbursements for durable medical equipment (DME), prosthetics/orthotics, and supplies (DMEPOS) or the patients’ costs for wound care products used in the home. In an effort to keep consistent with the theme of this month’s Today’s Wound Clinic, consider this your “Business Briefs” potpourri related to ancillary services in wound care.

Meeting DME LCD Requirements

  Those MACs who oversee DME write LCDs that provide the coverage guidelines for DME suppliers. However, DME suppliers and patients need the assistance of qualified healthcare professionals in order to meet all LCD requirements. In fact, Medicare beneficiaries could be denied coverage for wound care management products if qualified healthcare professionals do not document the patients’ diagnoses to the highest level of specificity, do not fully document medical necessity in the medical record, and/or do not write detailed orders in the medical record.   To better appreciate the need for understanding the LCDs set fort by DME MACs, ask yourself the following questions:     1. When I review pertinent LCDs, do I include the DME MAC LCDs for the products I order for home use?     2. Have my patients ever returned to my clinic/office without the surgical dressing or the orthotics that I ordered because the products were “too expensive”?     3. Has the DME supplier ever told me “Medicare does not cover the surgical dressings that I ordered for a patient’s use at home”?   If you answered “yes” to these three questions, please read this article very carefully. It is essential that you know the qualified healthcare professional’s obligations for justifying the medical necessity for all products ordered for at-home use. This can be achieved by following the DME MAC LCDs.   If Medicare patients purchase the Medicare Part B supplement, they should only be required to pay 20% of the Medicare allowable for their at-home dressings and orthotic footwear.   If the patients perceive the products are too expensive, the DME supplier may have been forced to charge the patients for the full price of the products because your written order and your written documentation did not support the medical necessity required by the LCD. If the DME supplier reports that Medicare does not cover the ordered product, that is not usually the exact problem: The real problem usually has something to do with a non-specific diagnosis, an incomplete order, and/or incomplete or non-existent documentation to support the medical necessity required by the LCD.

Where to Find Medicare LCDs

  The Centers for Medicare & Medicaid Services (CMS) maintain an Internet database of all published LCDs (active, draft, future effective, and retired).   While you may be accustomed to searching that database for those LCDs published by the MAC that processes your claims, you will also conveniently find LCDs that pertain to the products that you order for patients’ use in the home by searching the same coverage database link and by following the navigation steps itemized below (www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx):     • indexes     • local coverage   • LCDs by state (select your state)   • active LCDs   • submit   • DME MACs/program safeguard contractors/regional carriers (Click on the link to your DME MAC).   Review the list of LCDs and click on the LCDs that pertain to the products that you order for patients’ use in the home. For example:       • ankle-foot/knee-ankle-foot orthosis       • negative pressure wound therapy (NPWT) pumps       • orthopedic footwear       • surgical dressings       • therapeutic shoes for persons living with diabetes.

What Pairs of the DME MAC LCDs Are Important to Qualified Healthcare Professionals?

   First, qualified healthcare professionals should review the “Indications and Limitations of Coverage and/or Medical Necessity” section of the DME MAC LCD. There, you will find the MAC’s coverage criteria that must be met to prevent denial of the claim because the product is not reasonable and necessary. Both the surgical dressing and orthopedic footwear LCDs list the following coverage criteria:       • A signed, dated, detailed written order must be received by the supplier before a claim is submitted.       • The orthotic footwear LCD also states prosthetic shoes (L3250) are covered if they are an integral part of a prosthesis for a beneficiary with a partial foot amputation and lists specific covered ICD-9 diagnosis codes. (See your LCD for the specific covered ICD-9 diagnosis codes listed in this section and in the section entitled “ICD Codes that Support Medical Necessity.”)    The surgical dressing LCD discusses many other issues in this section (see your LCD for specific details):       • length of coverage       • coverage when used with investigational wound healing therapy       • use of dressings with adhesive borders versus use of tape       • use of products with Healthcare Common Procedure Coding System codes described as “wound fillers” and “wound covers”       • restrictions for use of hydrating dressings and absorptive dressings on the same wound       • inappropriate combinations of primary and secondary dressings that have different frequency-of-change guidelines      • guidance for selecting appropriate size of dressing to match the wound size     • guidance for determining the amount of dressings that should be dispensed at any one time     • order requirements for surgical dressings provided in kits     • coverage guidelines for each category of surgical dressings that specify:       — appropriate wound type       — covered frequency of dressing change       — number of dressings/amount of tape covered per dressing change       — restrictions when used in combination with another dressing.   Second, qualified healthcare professionals should carefully review the “Documentation Requirements” section of the DME MAC LCD and build those requirements into their medical record documentation. Both the surgical dressing and orthopedic footwear LCDs state that the patient’s medical records must reflect the need for the care provided. The patient’s medical records include the physician’s office records, hospital records, nursing home records, home health agency records, test reports, and records from other qualified healthcare professionals.   The surgical dressing LCD itemizes additional information that must be documented:     • number of surgical/debrided wounds being treated with a dressing     • reason for dressing use     • use as a primary or secondary dressing or for some noncovered use     • clinical information that supports the reasonableness and necessity of the type and quantity of surgical dressings ordered     • evaluation of wound on a weekly or monthly basis (see LCD for frequency of evaluation guidelines) requirements:       — type of each wound       — location of each wound       — size (length x width [cm]) and depth of each wound       — amount of drainage of each wound       — any other relevant information about each wound.   Third, qualified healthcare professionals must write orders that include all the LCD order requirements. (See Table 1 for professionals who are authorized to write orders.) Medicare requires an order for every DMEPOS item. Most items are dispensed based on verbal orders while some items (eg, support surfaces and NPWT) require written orders prior to delivery.   Detailed written orders are used to confirm what was ordered by the treating qualified healthcare professional following the supplier’s receipt of a verbal or written dispensing order.   Some DME suppliers use preprinted forms that include a listing of many different items for their detailed written orders. The qualified healthcare professional must clearly identify the specific items (eg, by checkmarks, circling items, or other affirmative indicators) that he/she is ordering for that specific patient. The qualified healthcare professional must sign and date the form. Reminder: The signature must be handwritten or an electronic signature. Stamp signatures are not acceptable.   Dispensing orders (verbal or written) that allow the DME supplier to deliver the product should include the following elements:     • description of item     • name of beneficiary     • name of physician     • start date of order     • signature       — written dispensing orders need a qualified healthcare professional’s signature       — verbal dispensing orders need the DME supplier’s signature.   Detailed written orders from a qualified healthcare professional are required before a DME supplier can submit a claim to a Medicare contractor. The detailed written order is required even if the item was dispensed based on a verbal dispensing order. All detailed written orders should include the following elements:     • beneficiary’s name     • physician’s name     • date of order and start date (if start date is different from date of order)     • detailed description of item(s) (See the LCD for specific requirements for selected items.) NOTE: The detailed description may be completed by someone other than the physician.     • frequency of change or use and specific amounts to be dispensed. NOTE: “As needed” is not an acceptable order.     • duration or length of need     • physician signature and signature date. NOTE: The surgical dressing LCD also specifies when new orders are required.   Finally, qualified healthcare professionals should review the article(s) that is/are frequently attached to LCDs.   These articles often provide additional coverage rules. For example, the article for surgical dressings states: Surgical dressings are covered when either of the following is met:     • they are required for the treatment of a wound caused by, or treated by, a surgical procedure, or     • they are required after debridement of a wound.   The surgical procedure or debridement must be performed by a physician or other healthcare professional to the extent permissible under state law. Debridement of a wound may be any type of debridement: surgical, mechanical, chemical, or autolytic.

Summary

  Wound care providers should take the time to download and read the entire LCD and article for surgical dressings and for orthotic footwear, as well as any other pertinent LCD/article.   Make a concerted effort to be very specific about the patients’ diagnoses, to document (in the medical record) the medical necessity for all work and products that will be ordered, and to write dispensing orders and detailed written orders in the medical record as well as on DME supplier order forms.   In recent Comprehensive Error Rate Testing (CERT) audits on DMEPOS claims, the audits found errors in the following categories:     • insufficient documentation     • medically unnecessary service or supply     • services incorrectly coded     • no documentation.   Don’t wait for a CERT audit. Instead, compare your medical record documentation and orders to the pertinent LCDs/articles. Then retrain yourself to document in detail and to write detailed orders in the medical record and on DME supplier order forms. Kathleen D. Schaum is president and founder of Kathleen D. Schaum & Associates Inc., Lake Worth, FL. She may be reached for questions and consultation at 561-964-2470 or kathleendschaum@bellsouth.net.