Expert Offers Tips on Navigating LCDs with ICD-10

Rheumatology managers recently received an overview of Medicare local coverage determinations (LCDs) that will be used when the International Classification of Diseases, Tenth Edition (ICD-10) takes effect in 2015. At the National Organization of Rheumatology Managers (NORM) 2014 Annual Conference, Jean Acevedo, president, Acevedo Consulting Incorporated, Delray Beach, FL, discussed the ins and outs of LCDs, providing tips and practical solutions.

Ms Acevedo’s presentation was one of several that were delivered to a general session audience at the conference, which was held September 12-13 in Louisville, KY. Practice managers, practice administrators, managing partners, and others at the conference gathered to learn about local coverage determinations, which serve as the framework for determination of whether treatments and services are reasonable and necessary and will be reimbursed as a Medicare benefit under Part A or Part B.1

“Understand that because ICD-10 implementation is in the future, none of the information, unless I tell you otherwise, is final,” Ms Acevedo noted. “These LCDs are all in their proposed form, assuming that we actually do go to ICD-10 in October 2015. Hopefully they won’t make any additional changes.”

All LCDs have the same format, noted Ms Acevedo, and include items such as an effective date, the Current Procedural Terminology codes that are covered within it, the ICD-9 or ICD-10 codes that support medical necessity, and the documentation requirements. Ms Acevedo said the person in the office who is responsible for billing should read each applicable LCD in the context of a patient’s situation and the clinical documentation. She also said it is important to read information about LCDs on the Centers for Medicare & Medicaid Services website.2

She provided a sampling of LCDs used in rheumatology and their accompanying ICD-10 codes. Among them was Cahaba Government Benefit Administrators LCD (L34257) for infliximab infusion with the ICD-10 code. The LCD includes unit equivalents for numbers of vials: 1 vial is 10 units, 2 vials are 20 units, and so on. Ms Acevedo said Cahaba likely did this because of previous underpayments or overpayments in cases when not all of the contents were used from each of the vials.

She noted the indications in L34257 are identical to those from the FDA, while the documentation requirements are identical to those in Cahaba’s current/active LCD for infliximab infusion, L30030. The documentation requirements stipulate, for example, that the medical records need to indicate the order, route of administration, amount of medication, and the clinical information supporting the indication for the use and frequency of usage for each patient.

“Cahaba is really pretty thorough when it comes to the actual documentation requirements,” said Ms Acevedo.

She suggested that each physician familiarize themselves with the ICD-10 codes that they will use frequently with their patient population. They can focus on one specific code/diagnosis set each month, and compare their accuracy in ICD-10 coding from the beginning of that month to the end. It will take approximately a year, she estimated, for the physician to become comfortable with the most common diseases he or she sees.

Ms Acevedo also delved into the details of some of the LCDs for bisphosphonate drug therapy, visco- supplementation, and intravenous bisphosphonates. She urged administrators to order enough ICD-10 books to allow everyone in their practices to become familiar with the rules. In addition, she said that in response to an additional development request or audit, it is important to submit all of the relevant information, including treatment note, the order or orders, the medical history and physical examination, and the posttreatment notes showing progress and response to treatment.

“You need to make sure that there isn’t a repeat of anything, even the injection of Depo-Medrol, without documentation to show that the patient responded well to the previous procedure. And also be sure to include anything else that you can think of that will support the indication, the medical necessity, and the ICD-10 code. So you don’t have situations in which you say, ‘Oh no, my nurses don’t document sometimes, in the confusion.’ Figure out how you want to support that correct documentation going forward and educate the clinical staff accordingly,” advised Ms Acevedo.

References

  1. US Centers for Medicare & Medicaid Services. Local coverage determinations. www.cms.gov/Medicare/Coverage/DeterminationProcess/LCDs.html. Accessed September 23, 2014.
  2. US Centers for Medicare & Medicaid Services. Indexes. www.cms.gov/medicare-coverage-database/indexes/national-and-local-indexes.aspx. Accessed September 23, 2014.

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