Wound Care Coverage Playbook

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.

  When the editors called and told me they wanted to dedicate this entire issue of Today’s Wound Clinic to Medicare Local Coverage Determinations (LCDs), I was watching one of the Final Four March Madness basketball games. As a graduate of a Big Ten University, my mind immediately gravitated to sports. One of the most valued documents of any athletic team is the “playbook”. I could not imagine what would have happened if the Final Four teams were given “football playbooks rather than basketball playbooks” or, worse yet, were not given any “playbooks!”

  We are very lucky that the Centers for Medicare & Medicaid Services (CMS), the major payer for patients with wounds, requires the local Medicare contractors to educate the providers in their jurisdictions via many manuals, newsletters, bulletins, National Coverage Determinations (NCDs), and Local Coverage Determinations (LCDs). As I speak with wound care providers all around the country, I learn that a few wound care professionals use these “playbooks” that their Medicare contractor provides. Unfortunately, many more wound care providers do not even know the name of the Medicare contractor that processes their Medicare claims and that writes their LCDs.

  When asked “Who is the Medicare contractor that processes your Medicare claims?,”hospital-based outpatient wound care department(HOPD) personnel and wound care professionals often respond in the following ways:
    •“CMS processes my claims.”
    •“What’s a Medicare contractor?”
    •“How can I find out – Who should I ask?”
    •“Why do I need to know – all I want to do is take care of the patients’ wounds and get paid?”

  When asked if they have all of the LCDs that pertain to the services, procedures, and products that they provide, HOPD personnel and wound care professionals frequently respond in the following ways:
    • What’s an LCD?”
    • “That is my [biller’s, coder’s, office manager’s, wound management company’s] job!”
    • “I don’t have time for such nonsense.”
    • “I don’t care about the LCD – all I care about is getting paid!”
    • “I expect the manufacturers to tell me what is covered!”
    • “I am getting paid without knowing about LCDs – why should I use my valuable time to find and read LCDs?”

  When DRAFT LCDs are released for public comment, HOPD personnel and wound care professionals frequently respond to the request for comments by saying:
    • “I am too busy seeing patients.”
    • “Let the wound care manufacturers worry about the LCDs.”
    • “Why should I comment, Medicare does not even read the comments?”
    • “If someone pays me to go to the public meeting, I will go.”

  These same providers often make very different comments when they are audited and if they must repay the Medicare program. Then their comments are:
    • “I wish I had paid more attention to you when you were trying to teach me the importance of LCDs.”
    • “I only wish I had read the LCDs myself!”
    •“I only wish I had gone through the LCD Reconsideration Process to educate the Medicare contractor about new published evidence that would have proved why XXXXX should be covered.”
    • “I could have easily incorporated the documentation guidelines into by dictation, electronic health record, etc., if only I had known the guidelines.”
    • “I shouldn’t have relied on the manufacturer’s interpretation of the LCD – they only told me the part that pertained to their product – they did not tell me the part that pertained to me.”

  To assist all HOPD personnel and all wound care professionals to understand the “who, what, where, and why” of LCDs, Today’s Wound Clinic is providing our readers with the following Wound Care Coverage Playbook. It is time that our readers take an active role in understanding their Medicare contractor’s LCDs that are pertinent to their work. That includes the entire wound care team: physicians, podiatrists, physician assistants, nurse practitioners, clinical nurse specialists, physical therapists, wound care nurses, dietitians, HOPD program directors, office managers, billers, coders, charge description managers, corporate compliance officers, etc.

  In addition to managing patients’ wounds, this team of wound care professionals must manage their wound care business. Wound care professionals tend to focus on the codes and their payment rates. However, just because a product, service, or procedure has a CPT® /HCPCS code and a payment rate does not mean that it is covered by the Medicare contractor.

  It is impossible to correctly manage a wound care business without consulting the coverage playbook of your major payer, your Medicare contractor’s Local Coverage Determinations (LCDs).

  Remember, Medicare does not provide “prior authorization”. The Medicare contractor’s LCDs are written to provide their coverage guidelines. Therefore, you must read the coverage guidelines before you perform your work. If your Medicare contractor covers a particular product, procedure, or service but does not cover it for your patient’s particular condition, you must give the patient an Advance Beneficiary Notice of Noncoverage (ABN) before you proceed. See the January/February 2009 issue of Today’s Wound Clinic for a full discussion about ABNs. If the product, procedure, or service is covered, you must not only understand the code for the item and the covered diagnosis code, but you must also understand the finite details for proving medical necessity, following the utilization guidelines, and documenting all the required clinical details.

  Many wound care professionals often ask me, “So I do not need to read the LCDs, will you just write a cheat sheet of what I need to know?” I am usually puzzled by that request and respond by saying, “And what part of that important document would you like me to leave out?” Once you have read an LCD, you may choose to write your own summary of key points that you do not want to forget. In the March 2011 issue of Today’s Wound Clinic Donna Cartwright provided you with a medical policy summary sheet that you might want to use for that purpose. But let me make it perfectly clear that only reading a summary sheet of an LCD or medical policy is not adequate. Each member of the wound care team needs to personally read each LCD and each medical policy. Remember that the LCDs and medical policies should be the “plays” in your Wound Care Coverage Playbook.

  Like Medicare, private payers typically publish medical policies. However, they usually require prior authorization because the patient’s individual policy may differ from the published medical policy. See the March 2011 issue of Today’s Wound Clinic for a discussion about prior authorizations. Medicaid programs often publish medical policies and usually require prior authorizations. To assist you in your search for private payer and Medicaid policies, Donna Cartwright has provided some valuable Web site links in Appendix A and Appendix B of the following Wound Care Coverage Playbook.

  The entire Editorial Board of Today’s Wound Clinic voted for this issue to be dedicated to Medicare Local Coverage Determinations. We hope you will read each “play” in the Wound Care Coverage Playbook to help you obtain and use your Medicare contractor’s “LCD plays”. As an added bonus, refer to the private payer and Medicaid links in Appendix A and B for assistance in locating those payers’ “medical policy plays”. Once you have followed all the plays in the Wound Care Coverage Playbook, I hope that you will be motivated to create your own playbook of Medicare LCDs and Articles and medical policies of the major private payers/State Medicaid programs for your wound care patients. Finally, I hope you will be motivated to take an active role in the LCD development and reconsideration process. Call me if I can be of assistance –I will be honored to assist you.

Play #1: Identify Services, Procedures, and Products That You Believe Should Be Covered by Medicare

  Play #1 must begin with answering the frequently asked question: “What is an LCD?” A Local Coverage Determination (LCD) is a decision by a Medicare contractor whether a particular service or item is reasonable and necessary and whether it should be covered. Medicare contractors develop LCDs when a National Coverage Determination (NCD) on a specific topic does not exist or when they need to further define an NCD. Contractors develop LCDs by considering medical literature, the advice of local medical societies and medical consultants, public comments, and comments from the provider community. The Medicare Program Integrity Manual states that “LCDs shall be based on the strongest evidence available. The extent and quality of supporting evidence is key to defending challenges to LCDs. The initial action in gathering evidence to support LCDs shall always be a search of published scientific literature for any available evidence pertaining to the item/service in question. In order of preference, LCDs should be based on:

    • Published authoritative evidence derived from definitive randomized clinical trials or other definitive studies, and
    • General acceptance by the medical community (standard of practice), as supported by sound medical evidence based on:
      o Scientific data or research studies published in peer-reviewed medical journals;
      o Consensus of expert medical opinion ( ie, recognized authorities in the field); or
      o Medical opinion derived from consultation with medical associations or other health care experts”

  An LCD may consist of two separate, though closely related documents: the LCD and an associated article. The major components of all LCDs are presented in TABLE I.

  Any non-reasonable and necessary language (benefit category, statutory exclusion, and coding guidelines) that a Medicare contractor wishes to communicate to providers may be done through an article attached to the LCD. Links to related articles are at the end of the LCD under the heading “Related Documents” or “LCD Attachments”.

  Contractors apply LCDs to Medicare claims on either a prepayment or postpayment basis. If the contractor decides to enforce an LCD on a prepayment basis, the contractor must design a Medical Review edit. Contractors have the flexibility to add, alter, or eliminate Medical Review edits at any time. Contractors cannot apply an LCD retroactively to claims processed prior to the effective date of the policy.

  Now that you can answer the questions “What is an LCD?” you and members of your wound care team should make a list of all the wound related services, procedures, and products that you believe Medicare should cover. Once the list is complete, you should attach the appropriate CPT® and HCPCS codes to the items on your list. Finally, you should make a list of “keywords” that describe the work you perform while managing patients’ non-healing wounds. See TABLE II for some “keywords” to get you started. Keep in mind, that many other “keywords” represent your work.

Play #2: Identify Medicare Contractor That Processes Your Claims and Writes LCDs That Pertain To Your Wound Care Business?

  The easiest way to identify the Medicare contractor that processes your Medicare claims and that writes the LCDs which pertain to your wound care business is to ask your billing department. For those of you who do not have billing departments, Play #2 will help you do the work yourself.

  Medicare contractors, known as Fiscal Intermediaries (FIs), have traditionally processed the claims and written the LCDs for hospital outpatient wound care departments (HOPDs). Medicare contractors, known as Carriers, have traditionally processed the claims and written the LCDs for physicians, podiatrists, and non-physician practitioners who manage wounds in all sites of service.

  In multi-disciplinary HOPDs, the facility and the professional staff often had different LCDs because different Medicare contractors wrote their LCDs and processed their claims. To rectify this differing LCD issue, to realize significant operational savings, and to improve the efficiency and effectiveness of the Medicare contractor processes, the Centers for Medicare & Medicaid Services (CMS) decided to divided the country into fifteen (15) A/B Medicare Administrative Contractor (MAC) jurisdictions and to issue Requests for Proposals for one MAC to manage all the Part A and Part B (with the exception of durable medical equipment suppliers, home health agencies, and hospice) work in that Jurisdiction.

  Once implemented, the same A/B MAC writes the LCDs and processes claims for the HOPD and the physicians, podiatrist, and non-physician practitioners. ONE EXCEPTION: Large chain providers are permitted to request the opportunity to consolidate their billing activities under the MAC with Jurisdiction over the chain’s home office. In that case, the HOPD and wound care professionals could still have differing LCDs if the chain’s home office is in a different State than the HOPD. The EXHIBIT 1 map shows the States and territories that are in each of the current 15 A/B MAC Jurisdictions. You can easily locate your Medicare Jurisdiction on the map.

  CMS believes that reducing the number of A/B MACS to 10 will further improve the efficiency and effectiveness of the MAC processes. Over the next several years, CMS will consolidate five current Jurisdictions (2, 6, 7, 8, and 14) with five other Jurisdictions (3, 5, 4, 15, and 13). The EXHIBIT 2 map shows the States and territories that will be in the 10 future A/B MAC Jurisdictions.

  Keep in mind (despite Medicare’s master plan to have the same Medicare contractor process both the HOPDs’ and the physicians’ Medicare claims} the master plan has still not been fully implemented. See TABLE III for a review of the status of the conversion from FIs and Carriers to A/B MACs. You can easily determine the status of your State’s conversion to an A/B MAC.

  In situations where the A/B MAC has not been implemented, the HOPD and physicians who work there could still have different Medicare contractors. Therefore, the LCDs pertinent to the physician and the HOPD could be different. In those circumstances, wound care providers should consider implementing the most restrictive LCD guidelines. If you are in a State that has not converted to an A/B MAC, you must identify the FI or Carrier that is processing your Medicare claims and writing your Medicare LCDs. As recommended at the beginning of Play #2, contacting your billing department is the easiest way to identify your Medicare contractor if you have not converted to an A/B MAC.

Play #3: Assign Someone to Obtain and Monitor LCDs on an Ongoing Basis

  One person should be assigned to research the LCD’s that pertain to all the services, procedures, products, and keywords you listed in Play #1. As that person locates each of the numerous pertinent LCDs, he/she should print a copy of each LCD, of each related document, and of each LCD attachment for every member of your wound care team. The team should then have a meeting to discuss the implementation of each LCD. Some LCDs will require updates to charge sheets and charge description masters. Some LCDs will require major changes to your documentation [of assessment, of all steps in surgical procedures (even when performed bedside), of other adjunctive care, etc.], more specific diagnosis descriptions, etc. Some LCDs will require that changes be made to your electronic health record – be sure to require your software vendor to make the changes that will help you comply with LCD documentation requirements.

  The person who is assigned to conduct your LCD research should review the LCD database on a monthly basis. He/she should research the active LCDs for revisions that were made that did not require public comment. He/she should also research DRAFT LCDs for new/revised LCDs that are open for public comment. Those LCDs should be brought to the attention of the team ASAP because the comment period is short and you do not want to miss the opportunity to make your voice heard both in written form and by presenting at the LCD public meetings. He/she should also research Future Effective LCDs because they will become effective 45 days from the day they were posted on the website. That is the time when the wound care team should make any changes necessary to be compliant when the new LCD becomes effective.

  You may think that monthly review of the LCD database is “overkill”. Remember this: Medicare contractors can release new/revised LCDs as often as they deem necessary, and providers and beneficiaries can initiate the LCD Reconsideration Process whenever they believe they have clinical evidence that will change the LCD. CMS actually updates the Medicare Coverage Database every week – usually on Thursday. By only reviewing the LCD database on a monthly basis, your wound care team can possibly have already missed 3 weeks of coverage changes. Therefore, monthly monitoring of the LCDs is necessary to keep you informed of Medicare coverage that pertains to you and your patients. The person assigned to monitor the LCDs may find it helpful to sign up for their Medicare contractor’s reimbursement and coverage updates listserv. Then all the LCD changes will be sent directly to that person’s e-mail at the time the update occurs.

Play #4: Obtain Pertinent LCDs from Your Medicare Contractor’s Web Site and/or from the Medicare Coverage Database

  Each Medicare contractor has a section of their website which contains all of their LCDs. See TABLE IV for links to the Medicare Contractor’s websites.

  In addition, the Centers for Medicare & Medicaid Services’ (CMS) Medicare Coverage Database (MCD) contains all the Medicare contractors’ LCDs and local articles: https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx. The MCD offers multiple ways to locate and view the documents: the navigation is clearly explained, including a PowerPoint demonstration which can be found under Related Links.

  For example: if you wish to view the title of all the LCDs that have been released by your Medicare contractor, simply click on the following:
    ➢ Indexes
    ➢Local Coverage
    ➢ LCDs by State
    ➢ State you would like to see
    ➢ Your Medicare contractor
    ➢ LCD type: Active Documents; Retired Documents; Future Effective Documents; or Draft Documents
    ➢ Submit
    ➢ Select the LCD title you would like to view
    ➢ Review the license page and “accept” if you agree
    ➢ Print the LCD; scroll to the bottom to locate any Related Documents or LCD Attachments
    ➢ Right click on Related Documents and/or LCD Attachments and Print any that are available

Play #5: Provide Comments When LCDs are in the DRAFT Stage

  Wound care professionals can provide comments and recommendations in the following situations:
    • All new LCDs
    • Revised LCDs that restrict existing LCDs (eg, when non-covered indications are added to an existing LCD; when previously covered diagnosis codes are deleted)
    • Revised LCDs that make a substantive correction (eg when a contractor identifies an error published in an LCD that substantively changes the reasonable and necessary intent of the LCD)

  Medicare contractors must post draft LCDs on the websites. The websites must clearly indicate the start and stop date of the comment period and must list an e-mail and postal address to which comments can be submitted. The Medicare contractor must provide a minimum comment period of 45 calendar days. The contractor must provide open meetings for the purpose of discussing draft LCDs. To accommodate those who cannot be physically present at the meeting, contractors shall provide other means for attendance (eg, telephone conference) and accept written or e-mail comments. These Public Open LCD meetings are the perfect forum for wound care professionals to provide in-person comments and recommendations to the Medical Director of the Medicare contractor. Don’t miss this opportunity to make your voice heard!

  In all cases, the Medicare contractor must consider each comment and recommendation that is made for the draft LCDs. After the contractor considers all comments, the contractor must post to their Web site a summary of comments received with the contractor’s response. This comment/response document must be posted prior to or on the start date of the notice period. The comment/response document must be posted (remain visible) on the Web site for at least a 6 month period.

  Additionally, the contractor must post the LCD that has been revised (based on the comments received) and must provide a minimum notice period of 45 calendar days before the final LCD becomes active. The contractor must also publish a summary of the final LCD in a news bulletin. The LCD will become active on the 46th calendar date after the notice period began.

  Medicare contractors must post to their Web sites an LCD status page that includes the draft LCD title, the date the draft LCD was released for comment, the e-mail and postal address where comments can be sent, the end date of the comment period, the current status (See TABLE V for a list of LCD Status Indicators), the date of Release for Notice, and the website link to the active LCD.

  Wound care professionals are not given an opportunity to provide comments and recommendations in the following situations:
    • Revised LCDs that liberalize existing LCDs ( eg, when a revised LCD expands the list of covered indications/diagnoses)
    • Revised LCDs that are issued for compelling reasons and Obtained Regional Office Approval (eg, when the LCD pertains to a highly unsafe procedure/device)
    • Revised LCDs that make a non-substantive correction ( eg, when a typographical or grammatical error is corrected and does not substantially change the LCD)
    • Revised LCDs that make a clarification (eg, when information is added that clarifies the LCD but does not restrict the LCD)
    • Revised LCDs that make a non-discretionary coverage/payment/coding update ( eg, when contractors update LCDs to reflect changes in NCDs, coverage provisions in interpretive manuals, payment systems, HCPCS, ICD-9-CM)
    • Revised LCDs that make discretionary coding updates that do not restrict ( eg, adding or explaining a coding issue as long as the revision does not restrict the LCD)

Play #6: Use the LCD Reconsideration Process to Request Changes to Active LCDs

  Wound care professionals can use the LCD Reconsideration Process to request a revision to LCDS published in final form only (the whole LCD or any provision of the LCD may be reconsidered). Contractors shall consider all LCD reconsideration requests from:
    • Beneficiaries residing or receiving care in a contractor’s jurisdiction
    • Providers doing business in a contractor’s jurisdiction
    • Any interested party doing business in a contractor’s jurisdiction

  In addition, contractors have the discretion to revise or retire their LCDs at any time on their own initiatives.

  Wound care professionals can find their Medicare contractor’s LCD Reconsideration Process on the contractor’s Web site home page or linked to another location: it will be labeled “LCD Reconsideration Process” and will include:
    • A description of the LCD Reconsideration Process, and
    • Instructions for submitting LCD reconsideration requests, including postal, e-mail, and fax addresses where requests may be submitted

  See TABLE IV for links to the Medicare Contractor’s LCD Reconsideration Process.

  LCD Reconsideration Process requests must be submitted in writing and must identify the language that the requestor wants added to or deleted from an LCD. Requests must include a justification supported by new evidence, which may materially affect the LCD’s content or basis. Copies of the published evidence must be included. The level of evidence required for LCD reconsideration is the same as that required for new/revised LCD development. Any request for LCD reconsideration that, in the judgment of the contractor, does not meet these criteria will be considered invalid. In addition, contractors have the discretion to consolidate valid requests if similar requests are received. See Table VI for the process that takes place once a requestor submits a valid LCD reconsideration request to the appropriate contractor.

Play #7: Communicate with Your Professional Society’s Medicare Carrier Advisory Committee (CAC) Representative

  Wound Care Professionals often think that manufacturers of products and devices used for wound care procedures should take the lead in obtaining positive LCDs. Actually, the Medical Directors of the Medicare contractors prefer to hear from the medical professionals, rather than the manufacturers. In fact CMS requires each Medicare Carrier to establish a Carrier Advisory Committee (CAC) in every State. The purpose of the CAC is to provide: 1) a formal mechanism for physicians in the State to be informed of and participate in the development of an LCD in an advisory capacity; 2) a mechanism to discuss and improve administrative policies that are within carrier discretion; and 3) a forum for information exchange between carriers and physicians. The CAC reviews all draft LCDs and advises the Carrier Medical Director, who makes the final LCD implementation decision.

  The CAC is composed of physicians, a beneficiary representative, and representatives of other medical organizations. The CAC members 1) disseminate proposed LCDs to and solicit comments from colleagues in their respective State and in their specialty societies; 2) disseminate information, to their respective State and specialty societies, about the Medicare program obtained at CAC meetings; and 3) discuss inconsistent or conflicting Medical Review policies.

  CAC members receive materials to be discussed at least 14 days in advance of their meetings. The CAC members are encouraged to discuss the material and disseminate it to interested colleagues within their specialty and to clinic or hospital colleagues for whom the item may be pertinent. The CAC members may bring comments to the CAC meeting or request that their colleagues send written comments to the Carrier Medical Director separately. The 45-calendar-day comment process required for all draft LCDs starts when the proposed LCD is distributed to the CAC committee members.

  All wound care physicians should contact their State medical specialty society to identify their CAC representative. When DRAFT LCDs are released and/or when an LCD Reconsideration Process request is needed, your CAC representative may be able to assist. Once your CAC representative understands your area of expertise, he/she may reach out to you and your other wound care colleagues when wound care related LCDs are on the CAC meeting agenda.

  When physicians contact this author about LCDs that they do not think are clinically correct, I always ask them if they have contacted their CAC representative. You guessed it – most physicians answer with another question, “What’s a CAC representative?” Now that you know about CAC representatives, be sure to take the time to contact your specialty medical society’s CAC representative, introduce yourself, and offer to assist with wound care related LCDs.

Play #8: During an Audit, Refer to the LCD that was Effective on the Date of Service Undergoing Review

  When conducting a Medicare audit involving coverage, the auditor will obtain the LCD that was effective on the date of service that is undergoing review. The auditor will compare claims and the patient’s medical record to the LCD guidelines that were in effect on the date of service.

  As you prepare for an audit, be sure to obtain the correct version of the LCD.

    • All active LCDs list the versions that were released for the past two years. Those past versions can be found at the bottom of each active LCD under the heading entitled “All Versions”.
    • The Medicare Coverage Database has a link to all versions of LCDs that are older than two years. To locate archived LCDs, follow this pathway: https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx
    ➢ Overview Tab
    ➢ Related Links
    ➢ External Links
    ➢ MCD Archive

  To be on equal grounds with auditors, wound care professionals should always have copies of the correct LCD versions.

Kathleen D. Schaum, MS, is President and Founder of Kathleen D. Schaum & Associates, Inc., Lake Worth, FL. Ms. Schaum can be reached at (561) 964-2470 or through her email address: kathleendschaum@bellsouth.net

Appendix A: Private Payer Website Links

  Prepared by: Donna J. Cartwright, MPA, RHIA, CCS, RAC, FAHIMA Senior Director, Strategic Reimbursement Services, Integra LifeSciences Corporation All private payers have Medical Directors and write medical policies. Wound care professionals should remember that private payers have a variety of plans with different benefits that may widely vary. For example: Two employers could offer health insurance through the same private payer. However, the benefit plan of one employer may cover a certain procedure and the benefit plan of the other employer may not cover the same procedure.

Appendix B: Medicaid Website Links

  Prepared by: Donna J. Cartwright, MPA, RHIA, CCS, RAC, FAHIMA Senior Director, Strategic Reimbursement Services, Integra LifeSciences Corporation