Updated on: November 28, 2016

Medical Necessity First Big Issue to Emerge Under ICD-10

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Original story posted on: October 7, 2015

The topic of medical necessity surfaced in the form of National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) during yesterday's ICD10monitor.com broadcast, "ICD-10: Five Days in Ten."

The first to report on the issue was Laurie Johnson, MS, RHIA, FAHIMA, who made the discovery Monday, saying that her "eyes nearly popped out" when it happened. Johnson reported her findings during yesterday's live broadcast, with corroboration provided by Kelly Whittle, also a panelist on the live broadcast.

 

"One issue that has been recently reported is a concern regarding medical necessity that includes NCDs and LCDs," said Johnson, the director of health information management for Panacea Healthcare Solutions. "In other words, some policies which did contain a non-specific code in ICD-9-CM no longer include that code for ICD-10-CM."

Johnson said that some organizations are planning to appeal these cases with the realization that the appeal process will delay reimbursement.

"Other organizations have identified that it was an issue from the medical necessity software," Johnson added.

One medical necessity issue reported on the American Health Information Management Association (AHIMA) listserv, Johnson noted, was LCD L33627 (non-invasive vascular studies) from National Government Services (NGS).

"The LCD includes arterial Doppler studies that previously included 443.9 (peripheral vascular disease, unspecified) in the ICD-9-CM version, but the ICD-10-CM version does not include I73.9, which is the translation of the unspecified code," she said.

Johnson said the more specific codes, I70.211 (atherosclerosis of native arteries of extremities with intermittent claudication, right leg) and I70.212 (atherosclerosis of native arteries of extremities with intermittent claudication, left leg) are covered.

"This oversight will create increased procedures/tests that do not have medical necessity," Johnson warned. "This oversight will also impact patients who will pay out-of-pocket or will refuse the test."

Johnson said she expects that other similar issues will arise.

"It is important to note that the Centers for Medicare & Medicaid Services (CMS) would address the NCDs while the specific Medicare Administrative Contractor (MAC) would address the LCDs," added Johnson, who contacted CMS regarding the issue. A response from the CMS ICD-10 Coordination Center to the question directed her to the following Web link: http://www.cms.gov/Medicare/Coverage/CoverageGenInfo/ICD10.html

Visitors to the site are directed to review this website for a list of contacts: https://www.cms.gov/Medicare/Coverage/DeterminationProcess/LCDs.html

"The War Room: Five Days in Ten," produced by ICD10monitor, continues through Friday, with daily broadcasts at 10 a.m. EST, when hospital representatives start calling in to report on how their facilities are faring in implementing ICD-10.

Laurie M. Johnson, MS, RHIA, FAHIMA AHIMA Approved ICD-10-CM/PCS Trainer

Laurie M. Johnson, MS, RHIA, FAHIMA, AHIMA Approved ICD-10-CM/PCS Trainer is currently a senior healthcare consultant for Revenue Cycle Solutions, based in Pittsburgh, Pa. Laurie is an American Health Information Management Association (AHIMA) approved ICD-10-CM/PCS trainer. She has more than 35 years of experience in health information management and specializes in coding and related functions. She has been a featured speaker in over 40 conferences. Laurie is a member of the ICD10monitor editorial board and makes frequent appearances on Talk Ten Tuesdays.

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