Managing Medicare Coverage Updates

on Tuesday, 11 June 2019. All News Items | Medicare Coverage

An Update on the Updates

The second week of each month, this newsletter features an article on Medicare coverage policies along with a listing of the latest new, retired and draft local coverage policies (LCDs and coverage articles). In addition, Medicare Administrative Contractors (MACs) are continually revising their existing active policies. These revisions may be as simple as correcting punctuation or as detailed as adding a new coverage indication and additional covered diagnoses. Local coverage policies are important to providers because they describe whether particular services are covered by Medicare for that MAC jurisdiction, the covered indications for the service including the covered diagnosis codes when applicable, and the documentation required to support the medical necessity of the service. When a Medicare contractor or affiliate audits your medical records to determine the appropriateness of payment for a service, they audit against the requirements described in the coverage policy and will deny your claim for the service if those requirements are not met.

If there is a policy that applies to the types of services your facility offers, what is the best way to keep up with revisions? Here are some tips to help providers stay current on their MAC’s policy updates.

  1. Make sure you are signed up for your MAC’s listserv. The MAC emails will include timely information on any updates and revisions to coverage policies.
  2. When a policy is revised, the easiest way to quickly assess the change is the Revision History Information at the bottom of the policy. You can access coverage policies through the Medicare Coverage Database where you can enter the policy ID number in the Quick Search field. There are also search options by state/region, title keywords, or CPT/HCPCS codes. The Indexes section of this site provides listings of policies by the MAC contractor or state. You can also find the policies on the MAC websites.
  3. Also watch for information from your MAC that offers a consolidated presentation of the revision details. For example, Palmetto GBA, the MAC for Jurisdictions J and M, includes the revision information for all policies revised within the last month in their monthly Medicare Advisory publications. Here is an example from the June 2019 JJ Part A Medicare Advisory.
Title
LCD Number
Revision Number
Changes/Additions/DeletionsEffective Date
Ambulance Services
LCD Number: L34549
Revision Number: 12
All verbiage regarding billing and coding under the Coverage Indications, Limitations and/or Medical Necessity section has been removed and is included in the related Billing and Coding: Ambulance Services A56468 article. Formatting and typographical errors were corrected throughout this section. 5/9/2019
Infrared Coagulation (IRC) of Hemorrhoids
LCD Number: L34422
Revision Number: 7
Under subheading Indications and Limitations verbiage was changed to read the medical literature has scant information regarding the long-term outcomes for IRC. However, given published outcomes similar to RBL even after five years, Medicare would not expect to see requests for repeat IRC payment until years after the initial treatment period and for only a minority of patients. Under subheading Bibliography changes were made to citations to reflect AMA citation guidelines. Formatting and punctuation were corrected throughout the LCD. Acronyms were inserted and defined where appropriate throughout the LCD. 5/9/2019

Some MACs may offer webinars or teleconferences about coverage policy updates. Novitas JL is offering an educational event on May 30, 2019 – “Local Coverage Determination Additions and Revisions: The class will discuss new Local Coverage Determinations (LCDs) and updates to existing LCDs. We will review new Local Coverage Articles and revisions. We will explore draft LCDs posted for comments and retired LCDs.” You can find information on how to register for this event on the Novitas Educational Event Calendar website.

  1. Involve the relevant department or service line with the coverage policies. Not every department manager needs to be on the MAC listserv, but assign a central person, such as someone in compliance or revenue integrity, to receive these emails. Then that person can distribute information to the affected areas. You want to do this for several reasons. First, managers of the relevant department or their designee are the ones who can likely affect changes to processes and documentation to ensure compliance with the policy requirements. They understand the policy requirements best since this is their forte. They are also the ones that likely care the most about the impact these policies potentially have on their services and reimbursement. As a result, they will generally be responsive to investigate revisions and take any needed actions.
  2. By the way, do not forget the national Medicare coverage policies – National Coverage Determinations (NCDs). You can sign up to receive CMS coverage email updates at the bottom of the main Medicare website.

As you can see, it is not an easy task to stay up to date on Medicare’s coverage requirements, but it is just another part of doing business with Medicare.

Recent new, retired and draft LCDs and Coverage Articles are listed in the table below.

 

 

Palmetto JJ and JM Coverage Updates

IDTitleEffective DateRevision Effective DateEnd DateLast UpdatedStatus
L37826  Lumbar Artificial Disc Replacement  5/6/2019 N/A  N/A  3/13/2019 New
L37863  Voretigene Neparvovec-rzyl (Luxturna™)  5/6/2019 5/6/2019 N/A  3/29/2019 New
L37873  Topical Oxygen Therapy  5/6/2019 5/6/2019 N/A  3/22/2019 New
L37848  Lumbar Spinal Fusion  5/6/2019 5/6/2019 N/A  3/13/2019 New
L34412  Cardiac Rehabilitation  10/1/2015 2/4/2019 4/5/2019 4/5/2019 Retired
A56584  Billing and Coding: Surface Electrical Stimulation in the Treatment of Dysphagia  5/23/2019 5/23/2019 N/A 5/15/2019 New
A56593  Billing and Coding: Foodborne Gastrointestinal Panels Identified by Multiplex Nucleic Acid Amplification (NAATs)  5/23/2019 5/23/2019 N/A 5/17/2019 New
A56580  Billing and Coding: Computerized Axial Tomography (CT), Thorax  5/16/2019 5/16/2019 N/A 5/9/2019 New
A56562  Billing and Coding: Health and Behavior Assessment/Intervention  5/16/2019 5/16/2019 N/A 5/9/2019 New

 

 

CGS J15 Coverage Updates

IDTitleEffective DateRevision Effective DateEnd DateLast UpdatedStatus
L37905  MolDX: Envisia, Veracyte, Idiopathic Pulmonary Fibrosis Diagnostic Test  5/20/2019 5/20/2019 N/A  3/29/2019 New
L37903  MolDX: Inivata, InVisionFirst, Liquid Biopsy for Patients with Lung Cancer  5/13/2019 5/13/2019 N/A  3/26/2019 New
L37608  MolDX: MDS FISH  5/6/2019 5/6/2019 N/A  3/19/2019 New
A56579  Billing and Coding for Paclitaxel; Taxol  5/16/2019 5/16/2019 N/A 5/9/2019 New
A56577  Billing and Coding for Docetaxel; Taxotere  5/16/2019 5/16/2019 N/A 5/9/2019 New
A56578  Billing and Coding for Infliximab; Remicade  5/16/2019 5/16/2019 N/A 5/9/2019 New
A56543  Billing and Coding for Durvalumab (Imfinzi)  5/9/2019 N/A N/A 5/1/2019 New
A56534  Billing and Coding for Denosumab (Prolia™, Xgeva™)  5/9/2019 N/A N/A 4/30/2019 New

 

 

 

First Coast JN

No updates this month      

 

 

 

National Government Services J6 and JK

No updates this month      

 

 

 

Noridian JE

IDTitleEffective DateRevision Effective DateEnd DateLast UpdatedStatus
L37818  MolDX: Decipher® Biopsy Prostate Cancer Classifier Assay for Men with Very Low and Low Risk Disease  5/27/2019 N/A  N/A  3/29/2019 New
L37887  MolDX: Envisia, Veracyte, Idiopathic Pulmonary Fibrosis Diagnostic Test  5/27/2019 N/A  N/A  3/27/2019 New
L37624  Helicobacter Pylori Infection Testing  5/27/2019 5/27/2019 N/A  4/5/2019 New
L37301  MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels  5/13/2019 N/A  N/A  3/13/2019 New
IDTitleComment Start DateComment End DateFinal Status
DL38155  Lab: Drug Interaction Testing  5/30/2019 7/15/2019 No   Draft
DL38143  MolDX: Decipher® Biopsy Prostate Cancer Classifier Assay for Men with Favorable Intermediate Risk Disease  5/30/2019 7/15/2019 No   Draft
DL38147  MolDX: Decipher® Biopsy Prostate Cancer Classifier Assay for Men with Unfavorable Intermediate Risk Disease  5/30/2019 7/15/2019 No   Draft
DL38127  MolDX: Guardant360® Plasma-Based Comprehensive Genomic Profiling in Solid Tumors  5/30/2019 7/15/2019 No   Draft
DL38119  MolDX: Next-Generation Sequencing for Solid Tumors  5/30/2019 7/15/2019 No   Draft
DL38123  MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies  5/30/2019 7/15/2019 No   Draft
DL38151  MolDX: Pigmented Lesion Assay  5/30/2019 7/15/2019 No   Draft
DL38131  MolDX: Prospera  5/30/2019 7/15/2019 No   Draft
DL38135  MolDX: TruGraf Blood Gene Expression Test  5/30/2019 7/15/2019 No   Draft
DL34228  Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF)  6/4/2019 7/19/2019 No   Draft

 

 

 

Noridian JF

IDTitleEffective DateRevision Effective DateEnd DateLast UpdatedStatus
L37820  MolDX: Decipher® Biopsy Prostate Cancer Classifier Assay for Men with Very Low and Low Risk Disease  5/27/2019 N/A  N/A  3/29/2019 New
L37891  MolDX: Envisia, Veracyte, Idiopathic Pulmonary Fibrosis Diagnostic Test  5/27/2019 N/A  N/A  3/27/2019 New
L37626  Helicobacter Pylori Infection Testing  5/27/2019 5/27/2019 N/A  4/5/2019 New
L37315  MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels  5/13/2019 N/A  N/A  3/13/2019 New
A56518  MolDX: Targeted and Comprehensive Genomic Profile Next-Generation Sequencing Testing in Cancer  5/27/2019 N/A N/A 4/17/2019 New
IDTitleComment Start DateComment End DateFinal Status
DL38139  Lab: Drug Interaction Testing  5/30/2019 7/15/2019 No   Draft
DL38145  MolDX: Decipher® Biopsy Prostate Cancer Classifier Assay for Men with Favorable Intermediate Risk Disease  5/30/2019 7/15/2019 No   Draft
DL38149  MolDX: Decipher® Biopsy Prostate Cancer Classifier Assay for Men with Unfavorable Intermediate Risk Disease  5/30/2019 7/15/2019 No   Draft
DL38129  MolDX: Guardant360® Plasma-Based Comprehensive Genomic Profiling in Solid Tumors  5/30/2019 7/15/2019 No   Draft
DL38121  MolDX: Next-Generation Sequencing for Solid Tumors  5/30/2019 7/15/2019 No   Draft
DL38125  MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies  5/30/2019 7/15/2019 No   Draft
DL38153  MolDX: Pigmented Lesion Assay  5/30/2019 7/15/2019 No   Draft
DL38133  MolDX: Prospera  5/30/2019 7/15/2019 No   Draft
DL38137  MolDX: TruGraf Blood Gene Expression Test  5/30/2019 7/15/2019 No   Draft
DL34106  Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF)  6/4/2019 7/19/2019 No   Draft

 

 

 

Novitas JH and JL

IDTitleEffective DateRevision Effective DateEnd DateLast UpdatedStatus
A56268  Coding Article for Sclerotherapy and Endovenous Non-Thermal Treatment of Varicose Veins  5/7/2019 5/7/2019 N/A 1/25/2019 New
A56505  Billing and Coding: Transesophageal Echocardiography (TEE)  4/25/2019 N/A N/A 4/18/2019 New
A56433  Billing and Coding: Hemophilia Factor Products  4/25/2019 N/A N/A 4/18/2019 New
A56473  Billing and Coding: Laboratory Panels  4/11/2019 N/A N/A 4/5/2019 New
A56440  Billing and Coding: eVox® System and Other Electroencephalograph Testing for Memory Loss  4/4/2019 N/A N/A 3/29/2019 New

 

 

 

WPS J5 and J8

IDTitleEffective DateRevision Effective DateEnd DateLast UpdatedStatus
L37772  MolDX: MDS FISH  5/13/2019 N/A  N/A  3/19/2019 New
L37911  MolDX: Decipher® Biopsy Prostate Cancer Classifier Assay for Men with Very Low and Low Risk Disease  5/13/2019 N/A  N/A  3/20/2019 New
L37919  MolDX: Envisia, Veracyte, Idiopathic Pulmonary Fibrosis Diagnostic Test  5/13/2019 N/A  N/A  3/20/2019 New
A56501  MolDX: Microsatellite Instability-High (MSI-H) and Mismatch Repair Deficient (dMMR) Biomarker Coding and Billing Guidelines for Patients with Unresectable or Metastatic Solid Tumors  6/10/2019 N/A N/A 4/17/2019 New
A56391  Implantable Automatic Defibrillators – Coding and Billing  5/13/2019 N/A N/A 3/19/2019 New

Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc.  Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system.  In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers.  You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information.  MMP, Inc. is not offering legal advice.  Every reasonable effort has been taken to ensure the information is accurate and useful.

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