Good News, Bad News The Saga Continues

The long awaited update to the CT lung screening NCD was finally released this July.  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 at least one MAC denied all of the claims submitted for DOS 2/5/15 through current.  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 and 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 is an inordinate amount of work and expense unnecessarily put on 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, it is still work but likely more feasible.  In dealing with software vendors, few, if any, are willing to program for “one offs” and significant time may be required.  So, the bottom line is that payments are still 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 payors is as yet unknown.  The issue and request for clarification has been brought to the attention of 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, no subsequent treatment code choices for intracranial hemorrhages.  In another case, although the LCD states only chronic conditions for a certain procedure are covered, the LCD includes only acute codes.  Conversations with the MAC and the regional offices confirm 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 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.

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 to be consistency among policies.  That has not even come close to fruition.  HBMA believes 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 October 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 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, EHR and coding software vendors.

In closing, the good news is CMS is aware of some of our providers’ most difficult MAC issues and willing to address them.  The bad news is we are still stuck with MAC policies that are inconsistent and not provider friendly.

Holly Louie, RN, CHBME, is the compliance officer for Practice Management Inc. and the 2016 HBMA president.

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