Newest MMP Report Identifies Coverage Risks

on Wednesday, 13 May 2015. All News Items | Outpatient Services | Medicare Coverage | Documentation

Help for the Weary

Hospitals are constantly struggling to follow everyone’s guidelines it seems – JCAHO, commercial payers, Medicaid, and Medicare, just to name a few. No wonder hospital staffs are weary, wary and stressed! Medical Management Plus (MMP) is proud to announce a new report that offers help for the weary.

In April, the Wednesday@One monthly Medicare coverage article discussed the importance of hospitals having a process in place to address Medicare coverage policies. Such a process should ensure compliance with the coverage requirements and prevent medical necessity denials as a result of failing to follow the coverage guidelines. One of the suggestions from the article is to evaluate coverage policies for services your facility offers that are “at risk.” Hospitals should consider the volume of the services they offer, the reimbursement amounts for these services, and the conditions of the policy. Another component in evaluating risk is recognizing the review targets of Medicare contractors and affiliates.

In order to assist our clients in determining services with potential risks associated with Medicare coverage policies, MMP is adding a new report to our HIQUP suite of reports. As we all know, Medicare manual instructions, Medicare National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) define the medical conditions, indications, and limitations for coverage of certain services. The new report identifies a facility’s financial risk should certain services be subject to a Medicare review. The select services have been identified by MMP as services at high risk because:

  1. They have significant reimbursement,
  2. The coverage determination requirements are quite detailed, and/or
  3. They are at increased risk of scrutiny by Medicare contractors or affiliates.

The new Medicare Coverage Policies Report will be launched in June and initially addresses six high risk services – AICDs and pacemakers, cardiac and pulmonary rehab, HBO, and sleep studies. Additional services will be added to the report over time for both national and local coverage policies specific to the client’s MAC region.

MMP recommends that providers verify their claims for these services meet all the appropriate criteria as specified in the coverage policy. A listing of the specific accounts is included in the HIQUP Account Listing Attachment and hyperlinks to the main coverage policy for each identified service are included in the report for easy access. Additional resources, including findings from reviews by MACs, Recovery Auditors, Supplemental Medicare Review Contractors, the OIG, and other Medicare reviewers if applicable, will be available through another hyperlink within the report that directs users to the Resources for Coverage Policies Guide on our website. This additional information allows providers to understand what issues have resulted in denials for other providers and what documentation specifics Medicare reviewers are looking for.

There is also a future benefit to knowing the coverage policies. As Medicare payments move from Fee-for-Service towards Value Based Purchasing, hospitals must find ways to provide the most effective care in the most efficient and cost-conscious manner. Appropriate utilization of services, that is performing only those services that are necessary for the patient’s condition and not performing unnecessary procedures, will be a major consideration in meeting this challenge. Facilities may find the Medicare coverage policies a useful tool in helping to determine the appropriate utilization of services.

We at MMP understand that providers are weary, stressed, and often overwhelmed by all the Medicare requirements. Hopefully our newest product will relieve some of the stress by giving hospitals the tools they need to ensure compliance and appropriate payments. MMP can also assist further by performing reviews if needed. If you already receive the HIQUP Reports, be on the lookout for the new Coverage Policies Report in your June reports. If you are not subscribed to our HIQUP Reports, but are interested, please contact me at This email address is being protected from spambots. You need JavaScript enabled to view it. .

Coverage updates for last month are listed below.

Cahaba J10 Coverage Updates

No updates this month

 

Palmetto GBA Coverage Updates

IDTitleComment Start DateComment End DateFinal Status
L31557 Ophthalmic Angiography (Fluorescein and Indocyanine Green) 1/24/2011 3/26/2015 4/6/2015  4/6/2015 Retired
L31602 Outpatient Observation Bed/Room Services 1/24/2011 2/12/2015 4/6/2015 4/6/2015 Retired
A54205 MolDX: MMACHC Test Coding and Billing Guidelines 4/23/2015 N/A N/A 4/16/2015 New

 

Novitas JH Coverage Updates

IDTitleEffective DateRevision Effective DateEnd DateLast UpdatedStatus
L35594 Lower Extremity Major Joint Replacement (Hip and Knee) 4/9/2015 N/A N/A 2/12/2015 New
L32622 Bioengineered Skin Substitutes 8/13/2012 1/1/2015 4/8/2015 4/8/2015 Retired
L32735 Hemophilia Factor Products 8/13/2012 1/1/2015 4/8/2015 4/8/2015 Retired
A54110 Speech Language Pathology (SLP) Services: Communication Disorders 4/9/2015 4/16/2015 N/A 4/10/2015 New
A54115 Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds 4/9/2015 N/A N/A 4/1/2015 New

 

Novitas JL Coverage Updates

IDTitleEffective DateRevision Effective DateEnd DateLast UpdatedStatus
L35594 Lower Extremity Major Joint Replacement (Hip and Knee) 4/9/2015 N/A N/A 2/12/2015 New
L27489 Monitored Anesthesia Care (MAC)  7/11/2008   9/1/2014  4/8/2015 4/8/2015   Retired
A54110 Speech Language Pathology (SLP) Services: Communication Disorders 4/9/2015   4/16/2015 N/A 4/10/2015  New 
A54115 Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds   4/9/2015 N/A  N/A 4/1/2015  New 

   

First Coast JN Coverage Updates

IDTitleComment Start DateComment End DateFinalStatus
DL36013 Application of Skin Substitute Grafts for Treatment of DFU and VLU of Lower Extremities 4/10/2015 5/24/2015 No Draft

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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