Part B Insider (Multispecialty) Coding Alert
Carriers Unveil Spate of Draft LMRPs
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Need summer beach reading? Your carrier may have just the thing. Carriers are putting out a number of draft local medical review policies for the summer with comments due by early August in most cases. For example, Noridian released a number of draft LMRPs affecting all 11 states that it covers. They include: Brachytherapy - Non-Intracoronary: This policy is based on a model LMRP developed by the American College of Radiology's Radiation Oncology Carrier Advisory Committee network, so it shouldn't prove too controversial. Radiographs may be used in brachytherapy simulations but shouldn't be reported as port films, the carrier states. Mammaplasty, Reduction: The carrier will pay to reduce the size of a breast where breast hypertrophy adversely affects other body systems, such as musculoskeletal, respiratory or integumentary, or where the surgeon reduces the size of a remaining breast to match a breast reconstructed after cancer surgery. The carrier won't pay for cosmetic procedures and requires both 611.1 plus another code to indicate macromastia, or both V58.42 and 174.x to indicate a reconstruction after cancer surgery. Transrectal Ultrasound or Echography: Noridian will pay for this test for specific conditions involving the rectum and surrounding areas, but won't pay for it as a screening for asymptomatic patients, to confirm a known diagnosis, to follow up a family history, or to examine benign lesions. Urodynamics: Noridian will cover a variety of urodynamic studies only after an initial examination, when the patient has an uncertain diagnosis and the physician can't develop an appropriate treatment plan, when the patient fails to respond to an adequate therapeutic trial, or when the patient is under consideration for urologic surgery. Meanwhile, CIGNA released an LMRP covering North Carolina for Resynchronization Therapy for Congestive Heart Failure. This non-pharmaceutical approach to CHF will be covered only if the patient meets four conditions. The patient must be symptomatic despite optimal therapy with angiotensin converting enzyme inhibitors and beta blockers and other pharmacologic measures. The patient must have symptoms of moderate to severe CHF, a left ventricular ejection fraction of less than 35 percent, and the duration of the QRS must be less than 130 ms.
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