All Entries Tagged With: "NCDs"
FIND quarterly updates
Flipping over the calendar from September to October means there are plenty of updates available to MedicareFind subscribers.
The latest versions of the NCCI edits, both on the physician and hospital outpatient side, have been loaded into our NCCI edit lookup tool. Keep in mind that the hospital outpatient edits are one quarter behind the physician edits.
The quarterly updates to the medically unlikely edits (MUE) is available. As before, some of the MUEs remain unpublished.
And you can now locate the following, in addition to other quarterly changes:
- Third quarter updates to OPPS Addendum A and Addendum B
- The October 2009 lab NCD manual
- The latest I/OCE update
Sign up for a free trial to MedicareFind to access updates like these and more.
CMS clarifies RACs’ “exception authority”
On September 11, CMS published Transmittal 302 that updated the Program Integrity Manual on Local Coverage Determination (LCD) exceptions. When specific authorized contractors conduct a complex medical review, they have the authority (in rare and unusual circumstances) to apply an exception to the “reasonable and necessary” requirements described in an LCD to approve or deny a claim. However, they cannot make exceptions to National Coverage Determinations (NCDs). In addition, and unless otherwise directed by CMS, RACs can only use the exceptions process to not deny a claim. This is a good time to review the difference between a national and a local coverage determination policy.
NCDs are coverage policies created by CMS for an item or service to be applied on a national basis for all Medicare beneficiaries. NCDs help ensure that access to advances in technologies that may improve healthcare are available to Medicare beneficiaries when those items and services are “reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member”. However, NCDs may also be used to bar payment for specific items or services that are not “reasonable and necessary”.
LCDs are determinations made by a fiscal intermediary, carrier, or Medicare Administrative Contractor (MAC) in regards to whether or not a particular item or service is covered on an intermediary-, carrier-, or MAC-wide basis. LCDs specify the circumstances under which a service is generally considered to be “reasonable and necessary” to assist providers in submitting correct claims for payment. Medicare contractors develop LCDs when there is no NCD or when there is a need to further define an NCD. The contractors must make sure that all LCDs are consistent with all statutes, rulings, regulations, and national coverage, payment, and coding policies. In addition, codes describing what is covered and what is not covered can be part of the LCD; however, coding guidelines are not elements of LCDs.
It will be important for providers to understand where to locate and how to use an NCD and/or LCD during the RAC review and appeal processes. More information on draft, current and retired NCDs can be found in the MedicareFind database or on the CMS web site. CMS requires all draft, final (active), and retired LCD information to be posted to each contractor’s website.
Never Events – Updated guidance on reporting surgical errors for Medicare inpatients
During the last few years, there has been considerable focus on certain events identified as “serious, largely preventable and of concern to both the public and health care providers.” These events have become more popularly known as “never events”—events that should never occur in a well-run healthcare facility with appropriate quality controls. In June of this year, Medicare released three national coverage determinations (NCDs) for the following surgical errors:
- Wrong surgical or other invasive procedure performed on a patient (NCD 140.6);
- Surgical or other invasive procedure performed on the wrong body part (NCD 140.7); and
- Surgical or other invasive procedure performed on the wrong patient (NCD 140.8).
Under the new NCDs, effective for services performed on and after January 15, 2009, CMS will not cover surgical or other invasive procedures performed in error, as described above. In addition, Medicare will also not cover hospitalizations and other procedures “related” to these non-covered services.
CMS announces a coverage determination on the “screening virtual colonoscopy”
On August 7, CMS issued transmittal R105NCD to implement its decision to maintain non-coverage of computed tomography colonography (CTC) for colorectal cancer screening, also known as a “virtual colonoscopy.” In 2008, the medical community had recommended that CMS consider coverage of this exam for screening purposes in specific individuals. After performing its own review, CMS has determined that the current medical evidence is inadequate and that no national coverage determination (NCD) is appropriate at this time.
Currently, Medicare beneficiaries can receive one of the following colorectal cancer screening tests:
- Fecal occult blood test (guaiac-based or immunoassay-based) once every 12 months;
- Flexible sigmoidoscopy once every 4 years depending on risk factors;
- Screening colonoscopy once every 10 years for patients without a known risk;
- Screening colonoscopy once every 2 years for patients at high risk for colorectal cancer;
- Barium enema every 4 years as a substitute for a flexible sigmoidoscopy;
- Barium enema every 2 years as a substitute for a screening colonoscopy for high risk patients.
Since CMS has determined that screening CTCs are non-covered for dates of service on and after May 12, 2009, a signed ABN is not required to be able to bill the patient for the service. However, under the revised ABN instructions, it can be used to inform the patient in advance of their financial responsibility.
More information on covered colorectal cancer screening services can be found in the Medicare Claims Processing Manual, Chapter 18, and the Medicare Benefit Policy Manual, Chapter 1.
Never Events—CMS issues surgical error NCDs and related guidance
In 2002, the National Quality Forum (NQF) published a list of 27 events identified as “serious, largely preventable and of concern to both the public and health care providers.” These events have become more popularly known as “never events”—events that should never occur in a well-run health care facility with appropriate quality controls. The updated list currently contains 28 adverse events, including the following surgical errors:
- Wrong surgical or other invasive procedure performed on a patient;
- Surgical or other invasive procedure performed on the wrong body part; and
- Surgical or other invasive procedure performed on the wrong patient.
New modifiers for outpatient never events; billing for hospital-acquired conditions
This week, CMS published the July Integrated Outpatient Code Editor (I/OCE). Although there were relatively few changes, CMS did introduce three new modifiers for use with the occurrence of three never events identified by the National Quality Forum (NQF) that were recently the subject of National Coverage Analyses by CMS. The new modifiers are: PA for surgical or invasive procedure on the wrong body part, PB for surgical or invasive procedure on the wrong patient, and PC for wrong surgery or invasive procedure on patient. The modifiers were added to the list of valid modifiers effective January 1, 2009.
Where to go to get your laboratory NCD information
This week, CMS published the laboratory Medicare National Coverage Determinations Coding Policy Manual and Change Report, containing medical necessity edits for 23 common diagnostic laboratory tests. CMS published a transmittal earlier in December announcing these changes, and the policies also appear in the Internet-only Medicare National Coverage Determinations Manual (NCD Manual). However, the best reference is the Policy Manual and Change Report. [more]
