Updated on: November 28, 2016

Good News, Bad News: The Saga Continues

Original story posted on: July 25, 2016
The long-awaited update to the CT lung screening national coverage determination (NCD) was finally released this month. As you may recall, current smokers who were otherwise eligible were omitted from the NCD-covered codes released last year. That is the really good news. The really bad news is that at least one Medicare Administrative Contractor (MAC) denied all of the claims submitted for dates of service running from Feb. 5, 2015 through the present day. The reason seems to be that their system was programmed to require both the diagnosis for a past history of smoking as well as the diagnosis for a patient who currently smokes on the same claim for service. 

Per the ICD-10 authoritative coding conventions, “personal history codes explain a patient’s past medical condition that no longer exists” for any patient who “is not receiving any treatment, but that has the potential for recurrence, and therefore may require continued monitoring.”  

Not only is this unexpected surprise incredibly frustrating, it represents an inordinate amount of work and expense unnecessarily demanded from providers and their billing companies. Either every claim must be recoded manually, or software must be programmed to automate the process. For those fortunate enough to have proprietary software and in-house programmers, this is still hard work, but likely more feasible.

Yet in dealing with software vendors, few, if any, are willing to program for “one-offs,” meaning significant time may be required. So the bottom line is that payments are still being withheld until providers do the work to overcome the edit. And 17 months of unpaid claims is not a small matter. 

How this will trickle down to Part C and commercial payers is as yet unknown. The issue and request for clarification has been brought to the attention of the Centers for Medicare & Medicaid Services (CMS) and Dr. Bill Rogers, the ICD-10 ombudsman. Hopefully, a quick resolution for providers will be the outcome.

This is just one example of the never-ending problems with local coverage determinations. Many still have glaring omissions from the conversions to ICD-10 last year. For example, there are no subsequent treatment code choices for intracranial hemorrhages. In another case, although the local coverage determination (LCD) notes that only chronic conditions for a certain procedure are covered, the LCD includes only acute codes. 

Conversations with MACs and the regional offices confirm that a formal process is required to have updates to these oversights and omissions. Simply pointing them out will not suffice. In fact, one MAC requested a review and listing of every identified issue for each LCD. My question is this: why didn’t you do that before it was published? The industry has been told many times that all NCD and LCD policies are thoroughly reviewed by coding experts prior to publication. I beg to differ. Res ipsa loquitor – this speaks for itself.

At a recent meeting with CMS, HBMA strongly advocated for the end of LCDs. An enormous amount of time is wasted each and every year by both the MACs and providers in wrestling with inconsistent and/or incorrect interpretations. This was greatly compounded with the implementation of ICD-10. When the old LMRPs were retired and LCDs introduced, the major benefit was supposed to be consistency among policies. That has not even come close to fruition. HBMA believes that this is counterintuitive to the goals of administrative simplification. The good news is that CMS did listen thoughtfully and carefully to the position. Time will tell if it will result in improvements. 

With such a large number of new codes coming this October, more issues seem highly likely. Close monitoring and review is recommended. The sooner omissions and errors are brought to the MACs’ attention, the sooner correct payments will ensue.

As part of their gracious allotment of time and attention, CMS also reminded HBMA attendees that the so-called grace period of audit specificity is ending Oct. 1, 2016. This has been an oft-misunderstood and misstated policy. The requirement for accurate and specific coding is the same as it has always been. The grace period was for auditing, not coding, and it was to allow less than the most specific codes within a family to be accepted, with certain exceptions, such as laterality. Given recent publications outlining significant errors on documentation and coding audits, this should be a very high priority for providers, electronic health record (EHR) managers, and coding software vendors.

In closing, the good news is that CMS is aware of some of our providers’ most difficult MAC issues and is willing to address them. The bad news is we are still stuck with MAC policies that are inconsistent and not provider-friendly.
Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Holly Louie, RN, BSN, CHBME

Holly Louie is the compliance officer for Practice Management Inc., a multi-specialty billing company in Boise, Idaho. Holly was the 2016 president of the Healthcare Business and Management Association (HBMA) and previously chaired the ICD-10 Committee. Holly is also a national healthcare consultant and testifying expert on matters related to physician coding, billing, and regulatory compliance. She has previously held compliance officer positions in local and international billing companies. Holly is a member of the ICD10monitor editor board and a popular guest on Talk Ten Tuesdays.

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