"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.
