Business Briefs: Read Medicare LCDs Before You Order Products and Equipment for Home Use

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 author 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. To view the referenced charts, subscribe to the print version of Today's Wound Clinic by visiting this link: https://50.28.4.247/subscribe-print-journal   Have you ever ordered surgical dressings, compression stockings, compression pumps, etc. for a patient’s use at home and received a call from the patient complaining that the durable medical equipment (DME) supplier said Medicare does not cover the items ordered? Very likely your first reaction is to tell the patient to use a different DME supplier. CAUTION: The problem may rest with the provider who wrote the order – not the DME supplier! Before providers quickly criticize and blame the DME supplier, they should take the time to do four things:     1. Call the DME supplier and learn “why” Medicare does not cover the item as ordered.     2. Go the internet-based Medicare Coverage Database and obtain the most current Local Coverage Determination (LCD) that pertains to the product(s) ordered.     3. Read the LCD and any attached Article(s)     4. Compare the LCD/Article guidelines to the documentation of medical necessity that is in the patient’s chart and to the order that was written for the product(s).   You may be pleasantly surprised to learn that Medicare does cover the item ordered, but cannot cover it due to something you did not do, something you did not supply, or something that you provided incorrectly. Physicians and non-physician practitioners who work in hospital-based outpatient wound departments (HOPDs) know that they should monitor the Local Coverage Determinations (LCDs), that pertain to the services, procedures, and products that they perform and use in the HOPDs, on a monthly basis. However, these professionals, who are authorized to write orders for medical supplies and equipment used by the patients at home, often forget to monitor the LCDs that pertain to those products.   Therefore, these ordering professionals may not include all the required information on the order, may have ordered the product to be changed more frequently than Medicare allows, may not have supplied required documentation to the DME supplier, etc. Because the DME supplier must follow the LCD guidelines, just like the ordering provider must follow LCD guidelines, the DME supplier is required to tell patients when Medicare will not cover products that are ordered. Of course, every DME supplier would like to make their customers happy by billing their insurance company and only collecting the required co-payment/coinsurance from the patient. When patients tell you that Medicare will not cover a medical supply or piece of medical equipment, take the time to call the DME supplier and uncover the reason. You may find that a more precise order, diagnosis code, and/or documentation may convert non-coverage to coverage for your patient.   Because Medicare contracts with different insurance companies to process DME suppliers’ claims and physicians’/non-physician practitioners’ claims, the LCDs pertaining to medical supplies and equipment will be found on the Medicare Coverage Database under the heading of DME MAC. Follow these simple steps to locate the pertinent medical supply and medical equipment LCDs on Medicare’s web site:     •www.cms.gov/mcd     •Index     •Local Coverage     •By Contractor     •DME MAC Select 1 of the 4.     •(See Table I)     •Submit Report     •Name of DME MAC     •LCD ID of either active, draft, future effective, or retired LCD pertinent to the product.   In keeping with the compression theme of the last two issues of Today’s Wound Clinic, let’s take a look at some of the LCD guidance that is available to providers who order compression products for patients’ use at home.   First, let’s look at what the LCD and attached Article for Surgical Dressings tell us about the use of compression bandages and gradient compression wraps. NOTE: Following are just a few excerpts from the LCD and Article – Providers Must Download and Read the Entire LCD and Article that is Posted on Their DME MAC’s Web Site.   Ask yourself if your orders would meet the following LCD/Article criteria:     •“For an item to be covered by Medicare, a written signed and dated order must be received by the supplier before a claim is submitted. If the supplier bills for an item without first receiving the order, the item will be denied as not medically necessary.”     •“The order must specify (a) the type of dressing (eg, hydrocolloid wound cover, hydrogel wound filler, etc.), (b)the size of the dressing ( if appropriate), (c) the number/amount to be used at one time ( if more than one),(d) the frequency of dressing change, and (e) the expected duration of need.”   Ask yourself if your documentation would include the following information required by the LCD/Article:     •“Information defining the number of surgical/debrided wounds being treated with a dressing, the reason for dressing use(eg, surgical wound, debrided wound, etc.), and whether the dressing is being used as a primary or secondary dressing or for some noncovered used ( e.g., wound cleansing) must be obtained from the physician, nursing home, or home care nurse. The source of that information and date obtained must be documented in the supplier’s records.”     •“Surgical dressings are covered when either of the following criteria are met:     •“They are required for the treatment of a wound caused by, or treated by, a surgical procedure; or         ºThey are required after debridement of a wound.”   Be sure you do not lead the patients to think that Medicare will pay for compression bandages and compression stockings that do not meet the following criteria. Pay particular attention to the sixth bullet point pertaining to venous insufficiency without stasis ulcers.     •“Light compression bandages (A6448-A6450), self-adherent bandage (A6453-A6455), and conforming bandages (A6442-A6447)are covered when they are used to hold wound cover dressings in place over any wound type.”     •“Moderate or high compression bandages(A6451, A6452) conforming bandages (A6442-A6447), self-adherent bandages (A6453-A6455), and padding bandages (A6441) are covered when they are part of a multi-layer compression bandage system used in the treatment of a venous stasis ulcer. All of these bandages are noncovered when used for strains, sprains, edema, or situations other than as a dressing for a wound.”     •“Most compression bandages are reusable. Usual frequency of replacement would be no more than one per week unless they are part of a multi-layer compression bandage system.”     •“Conforming bandage dressing change is determined by the frequency of change of the selected underlying dressing.”     •“A gradient compression stocking described by codes A6531 or A6532 or a non-elastic gradient compression wrap described by code A6545 is covered when it is used in the treatment of an open venous stasis ulcer”     •“Codes A6531, A6532, and A6545 are noncovered for the following conditions: venous insufficiency without stasis ulcers, prevention of stasis ulcers, prevention of the reoccurrence of stasis ulcers that have healed, treatment of lymphedema in the absence of ulcers. In theses situation, since there is no ulcer, the stockings/wraps do not meet the definition of a surgical dressing. Gradient compression stockings described by codes A6530, A6533-A6544, A6549 and surgical stockings described by codes A4490-A4510 are noncovered for all indications because they do not meet the definition of a surgical dressing.”     •“Coverage of a non-elastic gradient compression wrap (A6545) is limited to one per 6 months per leg. Quantities exceeding this amount will be denied as not medically necessary?”     •“A nonelastic binder for an extremity (A4465) is noncovered for all indications because it does not meet the definition of a surgical dressing.   Next, let’s look at what the LCD and attached Article for Pneumatic Compression Devices tell us. NOTE: Following are just a few excerpts from the LCD and Article – Providers Must Download and Read the Entire LCD and Article that is Posted on Their DME MAC’s Website.   Ask yourself if your orders would meet the following LCD/Article criteria. Also be very careful when you document the patient’s diagnosis and select the ICD-9-CM codes. The medical record and the Certificate of Medical Necessity (CMN) must match. (See Table II for some common ICD-9-CM definitions – NOTE: THIS IS NOT AN ALL-INCLUSIVE LIST!)     • “For an item to be covered by Medicare, a written signed and dated order must be received by the supplier before a claim is submitted. If the supplier bills for an item without first receiving the completed order, the item will be denied as not medically necessary.”     • “A Certificate of Medical Necessity (CMN) which has been completed, signed, and dated by the treating physician must be kept on file by the supplier and made available upon request. The CMN may act as a substitute for a written order if it contains all of the required elements of an order. The CMN for pneumatic compression pumps is CMS Form 846 (DME Form 04.04B)     • “If question #1 on the CMN (“Does the patient have chronic venous insufficiency with venous stasis ulcers?”) is answered “Yes”, documentation reflecting all of the following must be in the patient’s medical record and made available upon request.     1. The location of venous stasis ulcer(s)     2. How long each ulcer has been continuously present     3. Previous treatment with a compression bandage system or compression garment, appropriate dressings for the ulcer(s), exercise and limb elevation for at least the past 6 months     4. Evidence of regular physician visits for treatment of venous stasis ulcer(s) during the past 6 months.”   Ask yourself if the following medical necessity criteria stated in the LCD/Article are met and documented in the patient’s medical record.     • “Pneumatic compression devices are only covered for the treatment of lymphedema or for the treatment of chronic venous insufficiency with venous stasis ulcers.”     • “Pneumatic compression devices are covered in the home setting for the treatment of lymphedema if the patient has undergone a four-week trial of conservative therapy and the treating physician determines that there has been no significant improvement or if significant symptoms remain after the trial. The trial of conservative therapy must include use of an appropriate compression bandage system or compression garment, exercise, and elevation of the limb. The garment may be prefabricated or custom-fabricated but must provide adequate graduated compression.”     • “Pneumatic compression devices are covered in the home setting for the treatment of chronic venous insufficiency of the lower extremities only if the patient has one or more venous stasis ulcer(s) which have failed to heal after a six month trial of conservative therapy directed by the treating physician. The trial of conservative therapy must include a compression bandage system or compression garment, appropriate dressings for the wound, exercise, and elevation of the limb.”     • “For either lymphedema or chronic venous insufficiency with venous stasis ulcers, pneumatic compression devices are covered only when prescribed by a physician and when they are used with appropriate physician oversight, i.e., physician evaluation of the patient’s condition to determine medical necessity of the device, assuring suitable instruction in the operation of the machine, a treatment plan defining the pressure to be used and the frequency and duration of use, and ongoing monitoring of use and response to treatment.”     • “The determination by the physician of the medical necessity of a pneumatic compression device must include (1) the patient’s diagnosis and prognosis; (2) symptoms and objective findings, including measurements which establish the severity of the condition; (3) the reason the device is required, including the treatments which have been tried and failed; and (4) the clinical response to an initial treatment with the device. The clinical response includes the change in pretreatment measurements, ability to tolerate the treatment session and parameters, and ability of the patient (or caregiver) to apply the device for continued use in the home.”   Ordering providers should not create problems for the patients and the DME suppliers by ordering equipment that is not medically necessary and not covered by Medicare. For example: If treatments with either E0650 or E0651 pumps failed for six months, providers should meticulously document all the failed treatments before ordering E0652 pumps.     •“When a pneumatic compression device is covered, a non-segmented device (E0650) or segmented device without manual control of the pressure in each chamber (E0651) is generally sufficient to meet the clinical needs of the patient.”     • “A non-segmented compressor (E0650) with a segmented appliance/sleeve (E0671-E0673) is considered functionally equivalent to an E0651 compressor with a segmented appliance/sleeve (E0667-E0669).”     •“When a segmented device with manual control of the pressure in each chamber (E0652) is ordered and provided, payment will be based on the allowance for the least costly medically appropriate alternative, E0651, unless there is clear documentation or medical necessity in the individual case.”     •“Full payment for code E0652 will be made only when there is documentation that the individual has unique characteristics that prevent satisfactory pneumatic compression treatment using a non-segmented device (E0650) with a segmented appliance/sleeve (E0671-E0673) or a segmented device without manual control of the pressure in each chamber (E0651). If you order a segmented device with manual control of the pressure in each chamber (E0652), does your documentation meet this requirement?     • “If E0652 is billed, the following additional documentation supporting the medical necessity for this device must be substantiated by information in the patient’s medical records and available upon request:         º The treatment plan including the pressure in each chamber, and the frequency and duration of each treatment episode.         º Whether a segmented compressor without calibrated gradient pressure (E0651) or a non-segmented compressor (E0650) with a segmented appliance (E0671-E0673) had been tried and the results         º Why the features of the device that was provided are needed for this patient         º The name, model number, and manufacturer of the device.”   Providers should note that the Article attached to the LCD for Pneumatic Compression Devices closes with this reminder:   “The only products that may be billed to the DME MACs using codes E0650, E0651, and E0652 are those for which a Coding Verification Review has been made by the Pricing, Data Analysis, and Coding (PDAC) contractor and subsequently published on the appropriate Product Classification List.”   Providers can verify if a particular brand of surgical dressing (including surgical stockings, compression bandages) or pneumatic compression device has formally been assigned an HCPCS code, which is imperative for Medicare payment. In case you do not know how to locate the Product Classification Lists by brand and by HCPCS code, here are the steps to do so:     •https://www.dmepdac.com/     •DMECS Coding     •Select Classification: i.e., pneumatic compression device, surgical dressings,     •GO   If medical supplies and equipment are not listed on this web site, they do not have Medicare verified HCPCS codes. DME Suppliers will not be able to submit such products to Medicare for payment. Manufacturers of products without verified HCPCS codes should be encouraged to work with reimbursement specialists who are skilled in the completion of HCPCS Coding Verification Applications. Once the applications have been approved, those products will then appear on the Product Classification Lists by brand name. Providers should be cautious when vendors claim to have HCPCS codes for products that do not appear on the Product Classification Lists.   After reading the LCD and Article for Pneumatic Compression Devices, this author realized that it did not address the treatment of arterial disease, deep vein thrombosis (DVT) pumps, massage therapy pumps, post surgical DVT preventative pumps, etc. Upon further research of the PDAC website, I located an Advisory Article entitled Correct Coding for Pneumatic Compression Devices: https://www.dmepdac.com/resources/articles/2010/07_26_10.html.   It clearly outlines the compression devices that are deemed medically necessary for the various conditions:     • “Pneumatic compression devices used for the treatment of lymphedema and chronic venous insufficiency with ulcers are coded based upon the characteristics of the base device. The codes used are:         º E0650 pneumatic compressor, non-segmental home model         º E0651 pneumatic compressor, segmental home model without calibrated gradient pressure         º E0652 pneumatic compressor, segmental home model with calibrated gradient pressure”     •“Pneumatic compression devices used for the treatment of arterial disease are coded:         ºE0675 pneumatic compression device, high pressure, rapid inflation/deflation cycle, for arterial insufficiency (unilateral and bilateral system)”     •“Sleeves used with E0650-E0652 and E0675 are billed separately using codes E0655-E0673 depending upon the specific item provided.”     •“Pneumatic compression devices that are referred to as DVT pumps, massage therapy pumps, post surgical DVT preventative pumps, etc. are coded as:         º E0676 intermittent limb compression device (includes all accessories), not otherwise specified”     •“The garments/sleeves that are used with E0676 are included in the payment for E0676 on initial issue and must not be billed separately.”

Summary:

  Wound clinics and physicians who monitor and follow the Medicare LCDs and Articles that pertain to the products they use and the work they perform, as well as the LCDs and Articles for the products they order for patient use at home, will influence the providers’ and patients’ economical outcomes. Combined with their excellent clinical outcomes, all stakeholders should be satisfied! Kathleen D. Schaum, MS, is President and Founder 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. Subscribe to the print version of Today’s Wound Clinic now to receive exclusive information, which will help you grow the business end of your wound care clinic. Click Here Now