NCDs and LCDs Convert to ICD-10
Out With the Old, In With the New
We are now two weeks (14 days) into the conversion to ICD-10. Hopefully for your hospital the transition has been as smooth as possible and the inevitable issues of such a huge change are settling down. But having lived through change before, we all realize that issues will continue to come up for weeks and months. One such potential issue is with Medicare coverage policies – National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs).
Our usual article on the second week of the month lists new, retired and draft policies from each Medicare Administrative Contractor (MAC). You will not see that this month because all of the previously active policies from prior to October 1st were retired and new LCDs and Articles were made active to accommodate the change to ICD-10. The intent with these new policies was not to change the coverage requirements for any service, but to simply transition to I-10 codes. However, the conversion from I-9 to I-10 is not always as straight forward as it may seem and there is a chance that all the diagnoses covered in the retired I-9 policies may not have been appropriately forwarded to the new policies.
It would be particularly difficult for providers to read through each newly active policy and identify if any codes are missing. So what are providers to do to assure their services continue to be covered as before? Here are a few suggestions to address the transition of coverage policies.
- If there was a diagnosis, especially if it was an unspecified code, that you know supported medical necessity for a particular test frequently, look at the new policy and verify if the ICD-10 equivalent code is included.
- Make sure front end systems and pre-billing edits are up to date with the new ICD-10 coverage diagnoses, so that claims are halted for lack of medical necessity prior to submission. Have processes in place to investigate and address claims failing for lack of a covered diagnosis.
- Track your medical necessity denials by procedure code, by volume. If a procedure has an increased volume of denials after October 1st, determine the reason for the denial and make sure it is not related to a change in the policy requirements for diagnosis codes.
**If your internal systems are not capable of collecting this information, you may be interested in MMP’s Outpatient HIQUP (Hospital Improvement in Quality and Performance) report which analyses your monthly Medicare remittances and provides information on potential billing issues and denials, such as the volume of medical necessity denials by procedure code. Please contact MMP or visit our website (www.mmplusinc.com) for more information on our HIQUP report under the Products tab.
- If you discover an issue with a coverage policy where a diagnosis was covered pre-I-10, but is not now, address the issue with your MAC. MAC websites include instructions on how to request a Reconsideration of an LCD or Article. Use this process to request a code addition.
You can view all the newly active LCDs and Articles on your MAC’s website or on the Medicare Coverage Database. We are going to list new draft policies for all the MACs this month and also want to make you aware of a new NCD for coverage of Screening for Colorectal Cancer using CologuardTM.
CMS has determined that the evidence is sufficient to cover Cologuard™ - a multitarget stool DNA test – as a colorectal cancer screening test -
- Effective for dates of service on and after October 9, 2014
- For beneficiaries
- Age 50 to 85 years
- Asymptomatic (no signs or symptoms of colorectal disease including but not limited to lower gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test or fecal immunochemical test); and
- At average risk of developing colorectal cancer (no personal history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis; no family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer).
- Covered once every 3 years
- No coinsurance or deductible
- Performed by a laboratory authorized by the manufacturer to perform the Cologuard™ test
- Reported with HCPCS code G0464 (Colorectal cancer screening; stool-based DNA and fecal occult hemoglobin (for example, KRAS, NDRG4 and BMP3))
- Covered when reported on types of bill 13x, 14x, or 85x
- Requires diagnosis codes Z12.12 and Z12.11 for coverage
If you need more information about ICD-10 updates for NCD see the Medicare Coverage ICD-10 Information webpage. So out with the old and in with the new. It is keeping up with the new that is the challenge.
New draft LCDs from the previous month include:
Article by Debbie Rubio
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.