New LCD and LCA Documentation Requirements for Application of CTPs

© 2023 HMP Global. All Rights Reserved.
Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of Today’s Wound Clinic or HMP Global, their employees, and affiliates.

Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure accuracy. However, HMP and the author do not represent, guarantee, or warranty that coding, coverage, and payment information is error-free and/or that payment will be received.

If you are an ulcer management professional in a Medicare Jurisdiction serviced by CGS Administrators, LLC, First Coast Service Options, Inc., or Novitas Solutions, Inc. you are most likely aware of their new local coverage determinations (LCDs) and local coverage articles (LCAs) that pertain to skin substitute grafts/cellular and/or tissue-based products (CTPs) for the treatment of diabetic foot ulcers and venous leg ulcers. Kathleen Schaum’s Business Briefs article, entitled “As CTP Coverage Changes, Focus on What You Can and Should Do!” includes the links to the final coverage and coding documents, as well as the responses by the Medicare Administrative Contractors (MACs) to the comments received when the draft documents were released. Kathleen also provides an excellent list of Do’s and Don’ts to assist professionals align with the new coding and coverage guidelines in the 3 LCDs and LCAs.
 
Like all LCDs and LCAs, these new coverage policies contain extensive documentation guidelines. Because these coverage policies will become effective on September 17, 2023, now is the perfect time to evaluate and audit your documentation to ensure that all required elements are captured in your paper medical record or electronic health record (EHR). Therefore, this author prepared a documentation checklist (see Table 1) to evaluate your current documentation practices and to implement any needed documentation improvement processes. Compliance with the documentation requirements should minimize CTP claim denials.
 
NOTE: If you are serviced by other MACs, you can also use the documentation checklist to audit your compliance with your MAC’s LCD and LCA. If your MAC retired the pertinent LCD and LCA, you should locate them in the Medicare Coverage Archive file; the retired coverage documents will provide you with the documentation guidelines that those MACs expected. Tightening up your documentation now is important because these MACs could make similar revisions to their LCDs and LCAs in the future.
 
As in previous articles, this author suggests beginning your documentation review process by either 1) assembling your paper documentation or 2) printing the documentation from your EHR for a sample of patient encounters in which skin replacement surgery was performed. Then compare the documentation with the data elements that are required in the LCDs and LCAs. The Documentation Checklist should assist you to review each patient’s medical record and to ensure that:

• You follow documentation guidelines.
• You align with utilization parameters.
• Justify medical necessity of every skin substitute/CTP application.
• You use an ulcer naming system that is consistent, and clearly describes each ulcer site receiving a skin substitute/CTP, clearly identifies the CTP used and the entire procedure, and clearly describes the success/failure of each application as evidenced by reduction in ulcer size.
• You have a process in place to keep track of the number of applications performed on each ulcer.

 
To ensure continued success for your practices, this author sincerely hopes that stakeholders affected by these new LCDs and LCAs will review and refine their documentation of skin substitute/CTP applications prior to September 17, 2023. Those who take the time now to audit their own documentation will be glad they did!

Donna Cartwright is senior director of health policy and reimbursement at Integra LifeSciences Corp., Plainsboro, NJ. She is an AHIMA-approved ICD-10-CM/PCS trainer, and she has been designated as a fellow of the American Health Information Management Association.

Click here to download a PDF of this article.