The Secret to Proving Medical Necessity
Two Medicare cases illustrate the importance of NCDs and LCDs.
Proving medical necessity is really no secret at all: Medicare national coverage determinations (NCDs) and local coverage determinations (LCDs) dictate which diagnosis codes must be documented by clinicians to support the medical necessity of most services or supplies they provide to patients. Coders who are informed of these policies play an essential role in garnering uninterrupted cash flow for their clinicians.
NCDs vs. LCDs
NCDs are issued by the Centers for Medicare & Medicaid Services (CMS) at the national level —– meaning the policies apply to all Medicare providers. LCDs are issued by Medicare administrative contractors (MACs) or other payers at the local level. As such, LCDs may vary by state and carrier, even if they are for the same service or supply. Carriers other than Medicare may adopt these national/local policies and payment guidelines, as well.
When an NCD or LCD exists for a CPT® code being reported on a claim, one of the ICD-10 codes listed in that policy must be reported on the claim, too. Otherwise, the claim will be denied.
A provider or supplier cannot bill a Medicare patient for an uncovered service or supply unless they inform the patient prior to rendering the service or supply, and the patient signs an advanced beneficiary notice (ABN). Without a signed ABN on file, the patient is not liable for the charges, and the provider or supplier has no other choice but to write off the charges as lost revenue.
To illustrate, let’s review the encounters for two different Medicare patients.
Novitas Solutions, Part A and B MAC for jurisdictions L and H, has an LCD for hydration therapy (L34960). The LCD addresses CPT® codes:
96360 Intravenous infusion, hydration; initial, 31 minutes to 1 hour
+96361 each additional hour (List separately in addition to code for primary procedure)
Some covered indications for hydration (among others) on this policy are:
R11.2 Nausea with vomiting, unspecified
R42 Dizziness and giddiness
The patient’s emergency room note reads:
Patient presents with dizziness
Patient had episode of dizziness, lightheaded earlier today with a HR of approx 105. Patient’s brother-in-law had patient do some vagal maneuvers and ice to the face, which made him feel better. Patient has history of SVT ablation.
29 y/o male with PMH of SVT with ablation in 2005 p/w dizziness that began earlier this evening. While at dinner, patient felt sudden onset palpitations and dizziness. His brother-in-law tried some vagal maneuvers, which brought his pulse down and his dizziness resolved. Patient states that it happened to him again later this evening. He has not followed with a cardiologist recently but states this is the same way he felt back in 2005 when he was having episodes of SVT. Patient reports nausea, but no chest pain/SOB/syncope. On exam, VSS, heart RRR, lungs CTA, abd soft/nt/nd, no LE edema, neuro exam intact. Will order labs and IVFs.
Rhythm: Normal sinus rhythm at 69 beats per minute.
Axis: Normal axis.
Intervals: Normal PR interval.
QRS complex: Left bundle branch block.
ST segment: Normal ST-T segments.
QT interval: Normal.
Compared with prior: Unchanged.
Labs are all stable. Patient’s symptoms have all resolved. Patient’s heart rhythm has remained NSR on the monitor. Will d/c patient home in stable condition with f/u with his PCP. Also given referral to cardiology. Advised patient to return if he develops worsening/return of symptoms: dizziness/lightheadedness, palpitations, SOB, cp. Patient and family verbalize understanding and are in agreement with the plan.
Number of diagnoses or management options.
Dizziness: New and requires workup.
Amount and/or complexity of data reviewed.
Clinical lab tests: Ordered and reviewed.
Review and summarize past medical records: Yes.
Discuss the patient with other providers: Yes.
Final diagnoses: Dizziness
Based on this report, the encounter was coded ICD-10 R00.2 Palpitations and R42. The hydration will be paid.
Novitas’ LCD for multigated acquisition (MUGA) scans (L35083) addresses the following CPT® and diagnosis codes:
78472 Cardiac blood pool imaging, gated equilibrium; planar, single study at rest or stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without additional quantitative processing
78473 Cardiac blood pool imaging, gated equilibrium; multiple studies, wall motion study plus ejection fraction, at rest and stress (exercise and/or pharmacologic), with or without additional quantification
Group 2 Paragraph: Medicare is establishing the following limited coverage for Cardiac Blood Pool Studies through CPT® codes 78472, 78473, 78481, 78483, 78494, and 78496
|Group 2 Codes|
|I50.21 – I50.23||Acute systolic (congestive) heart failure – Acute on chronic systolic (congestive) heart failure|
|I50.41 – I50.43||Acute combined systolic (congestive and diastolic (congestive) heart failure – Acute on combined systolic (congestive and diastolic (congestive) heart failure|
|Z01.30*||Encounter for examination of blood pressure without abnormal findings|
|Z01.31*||Encounter for examination of blood pressure with abnormal findings|
|Z08*||Encounter for follow-up examination after completed treatment for malignant neoplasm|
|Z09*||Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm|
|Z51.11||Encounter for antineoplastic chemotherapy|
|Z51.12||Encounter for antineoplastic immunotherapy|
|Z51.81*||Encounter for therapeutic drug level monitoring|
Group 2 Medical Necessity ICD-10 Codes Asterisk Explanation: *CHEMOTHERAPY: Report Z01.30 – Z01.31 when the testing is performed as a BASELINE STUDY before chemotherapy; Report Z51.81 for SUBSEQUENT MONITORING while the patient is receiving chemotherapy; and report Z08 and Z09 for testing when CHEMOTHERAPY IS COMPLETED.
DEVICE PLACEMENT: Report ICD-10 codes I50.21 – I50.23 and I50.42 – I50.43 when using to support medical necessity only performed to calculate ejection fraction in those patients being actively considered for defibrillator or biventricular pacemaker placement, where ejection fraction is the detemining factor in the decision.
The report for the patient’s study reads:
Resulting lab: Radiology
History: 53-year-old female with malignant neoplasm of left breast.
Radiopharmaceutical and technique: Multigated cardiac scan was performed following the intravenous administration of 1.5 mg of cold stannous pyrophosphate and 18.3 mCi of Tc-99m labeled red blood cells.
Comparison is made to prior study from 7/15/15.
There is normal biventricular wall motion and chamber size. The calculated left ventricular ejection fraction is 60% which is above the normal lower limit of 50%. Right ventricular contractility is normal. The findings are unchanged compared to prior study from 7/15/15.
Incidental note is made of small round photopenia related to left breast tissue expander port.
Normal left ventricular wall motion and left ventricular ejection fraction at 60 percent, unchanged compared to prior study from 7/15/15.
Based on this report, the encounter was coded C50.912 Malignant neoplasm of unspecified site of left female breast. This claim will be denied.
Very likely the physician was ordering this as a pre-, peri-, or post-chemotherapy study (which are covered in this policy), but a lack of documentation prohibits reporting those codes.
Knowledge is Power
Familiarizing yourself with the NCDs and LCDs relevant to the services your practice or facility commonly offers, presents a great opportunity for you to offer feedback and education to your clinicians relative to their documentation. For instance, in the MUGA example, educating the oncology physicians on documenting their orders — whether the test is being done as a baseline before chemotherapy or as monitoring during/after chemotherapy — would ensure future tests were covered.
Jennifer Comstock, CPC, is a coding and billing analyst for Lehigh Valley Health Network. She has been in the billing and coding industry for 20 years, working all parts of the revenue cycle. Comstock works on claim edits, denials, appeals, and assists with audits. She is a member of the Allentown, Pa., local chapter.
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