CARRIER ADVISORY COMMITTEE REPORT 2011 Brent M. Harwood, DPM

Appeals process for Medicare can be viewed at: www.cahabagba.com/part_b/claims/appeals.htm

DMERC Phone Review Line (866)813-7878 DMERC is now allowing all doctors to use the “Phone Review Line” to make corrections to denied claims such as: Leaving off modifiers Wrong number of units entered on claim To change a HCPCS code Wrong POS

Correct Coding Initiative (CCI) Definition: helps promote national correct coding methodologies and controls improper coding CCI can be viewed through the web at: www.cms.hhs.gov/NationalCorrectCodInitEd/

How to Access Medicare Focuses: Medicare Focuses are no longer mailed to physicians but can be viewed at: www.cahabagba.com - Choose “Part B” - Look at Education & Outreach and click “Newsletters” Select the month and year to view Only goes back to 2009

What is on the Medicare Focus? News from Cahaba GBA and CMS such as: -Important provider contact center phone #’s -Any updates to LCD’s -Information about online courses -Updates to Claim Adjustment Reason Codes & Remittance Advice Remark Codes

Local Coverage Determination (LCD) & Medical Review Articles Shows important information on limitations, frequency, billing, & documentation requirements for certain CPT codes Can be accessed by going to Medicare’s website at: www.cahabagba.com - Click on Part B - Look under Popular Links for LCDs and Articles

Hospice Patients GW modifier added to an office visit or procedure when billing Signifies the service is not related to the diagnosis for which the patient is enrolled in hospice This allows for payment to the physician

HPSA Bonus Modifier HPSA Bonus Modifier QB was replaced with AQ effective 01/01/06 Updated list of zip codes for rural areas that qualify for HPSA Bonus can be found at: www.cahabagba.com - Click on Part B - Look under Financial - Click Health Professional Shortage Area (HPSA) & Physician Scarcity Areas (PSA)

New ABN Form ABN – advance beneficiary notice – applies to the Medicare fee-for-service program Revised ABN title is actually, “Advance Beneficiary Notice of Noncoverage” (CMS-R-131) Went into effect March 3, 2008 with a 6 month transition period; mandated use by March 1, 2009 Available at: www.cms.hhs.gov/bni

New Ulcer Code 97597 replaced 11040 and 11041 Meaning Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of whirlpool, when performed and instruction(s) for ongoing care, per session; total wound(s) surface area; first 20 sq cm or less When billing for BCBS AL patients 97597 is listed as physical therapy and therefore will go towards any deductibles first before paying

Ulcer Care Coverage Documentation Requirements In the Examination portion of the medical record document the following: - Ulcer size - Ulcer depth (I suggest partial/full/subcutaneous muscle/bone) - Appearance of ulcer (macerated, dessicated, infected)

Ulcer Care Coverage Documentation Requirements continued… In the Examination portion of the medical record document the following: - Status of the wound 1. Treatment will make a significant practical improvement in the wound in a reasonable and generally predictable period of time OR 2. If wound closure is not a goal, then the expectation is to optimize recovery and establish an appropriate non-skilled maintenance

Ulcer Care Coverage Documentation Requirements continued… In the Procedure/Plan portion of the medical record document one or all the following: - Treatment will: substantially affect tissue healing and viability reduce or control tissue infection, remove necrotic tissue prepare that tissue for surgical management

Ulcer Care Coverage Documentation Requirements continued… In the Procedure portion of the medical record document the following: - Other precautions have been taken to prevent the formation of new or perpetuation of existing ulcer (i.e. appropriate bedding, padding, patient turning, etc.) - Duration of ulcer - Frequency of ulcer treatments

Medicare assumes ulcers should not require more than 8 treatments in 6 months to heal

Ulcer Care Coverage Documentation Requirements continued… In the Procedure portion of the medical record document the following: - Modalities *vascular surgical intervention *surgical debridement *shoe gear alteration - Anticipated endpoint *at time of wound closure

Ulcer Care Coverage Documentation Requirements continued… In the Procedure portion of the medical record document the following: - Complications that have delayed healing Patient is non-compliant Patient has uncontrollable diabetes Patient has severe PAD Patient has biomechanical deformity causing pressure on wound

Ulcer Care Coverage Documentation Requirements continued… In the Procedure portion of the medical record document the following: - Projected number of additional treatments necessary 4 8 10 >10

Ulcer Care Coverage Documentation Requirements continued… In the Procedure portion of the medical record document the following: - That ulcer is either in need of debridement or not in need of debridement

Ulcer Care Coverage Documentation Requirements continued… In the Procedure portion of the medical record document the following: Depth that the ulcer was debrided, i.e. - partial thickness = 97597 - full thickness = 97597 - subcutaneous = 11042 - muscle = 11043 - bone = 11044

Ulcer Care Coverage Documentation Requirements continued… In the Procedure portion of the medical record document the following: Type of material removed, i.e. - necrotic - dessicated - macerated

Ulcer Care Coverage Documentation Requirements continued… In the Procedure portion of the medical record document the following: Method of debridement, i.e. - using #15 blade - using tissue nippers

PQRI Reporting Podiatry has 3 measures to report 1. Diabetic Foot & Ankle Care, Peripheral Neuropathy: Neurological Evaluation (Measure 126) 2. Diabetic Foot & Ankle Care, Ulcer Prevention: Evaluation of Footwear (Measure 127) 3. Diabetes Mellitus: Foot Exam (Measure 163)

PQRI Reporting continued… Must report the initiatives on at least 80% of eligible patient’s services during the reporting period Payment will be based on 1% of fees generated during the reporting period Reporting period for 2011: January – December Patient must have diagnosis of DM to be eligible for these measures

Diabetic Foot & Ankle Care, Peripheral Neuropathy: Neurological Evaluation (Measure 126) Patient must be 18 or older CPT to qualify for measure: - 11042 – 11044 - 11055 – 11057 - 11719 – 11721 - 11730 - 97597, 97598 - 99201 – 99205 - 99212 – 99215 Use CPT G8404 to report this measure

Diabetic Foot & Ankle Care, Ulcer Prevention: Evaluation of Footwear (Measure 127) Patient must be 18 or older CPT to qualify for measure: - 11042 – 11044 - 11055 – 11057 - 11719 – 11721 - 11730 - 97597, 97598 - 99201 – 99205 - 99212 – 99215 Use CPT G8410 to report this measure

Diabetes Mellitus: Foot Exam (Measure 163) Patient must be 18 through 75 CPT to qualify for measure: - 99201 – 99205 - 99212 – 99215 Use CPT 2028F to report this measure

Medicare Criteria to Dispense Diabetic Shoes Prescribing physician’s detailed written order Completed signed and dated statement from the certifying physician specifying that the beneficiary has diabetes and: a. Previous amputation of the other foot, or part of either foot, or b. History of previous foot ulceration of either foot or c. History of pre-ulcerative calluses of either foot or d. Peripheral neuropathy with evidence of callus formation of either foot or e. Foot deformity of either foot f. Poor circulation in either foot and is being treated under a comprehensive plan of care for his/her diabetes and needs diabetic shoes

Medicare Criteria to Dispense Diabetic Shoes continued... Relevant medical records where the certifying physician either personally documented that the beneficiary met one or more of criteria 2a – 2f or obtained documentation from another clinician documenting the beneficiary met one or more of criteria 2a – 2f and the certifying physician indicated agreement with the information by initialing and dating the record (Diabetic Screening Signed by Podiatrist and PCP) Supplier in-person evaluation conducted prior to selection of items that documents an examination of the beneficiary’s feet with a description of the abnormalities that will need to be accommodated by the shoes/inserts/modification

Medicare Criteria to Dispense Diabetic Shoes continued... In-person visit at the time of delivery which assesses the fit of the shoes and inserts with the beneficiary wearing them Delivery documentation with the beneficiary’s name and address and the description of the items provided (Receipt of DME) ABN

Services You Can’t Bill While Patient is in a Nursing Home or on Home Health 97597 X-rays DME items Home Health Wound care products

Thank You!!