1. CARRIER ADVISORY COMMITTEE REPORT 2011
Brent M. Harwood, DPM

2. Appeals process for Medicare can be viewed at:

3. 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

4. Correct Coding Initiative (CCI)
Definition: helps promote national correct
coding methodologies and controls
improper coding
CCI can be viewed through the web at:

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

6. 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

7. 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:
- Click on Part B
- Look under Popular Links for LCDs and Articles

8. 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

9. 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:
- Click on Part B
- Look under Financial
- Click Health Professional Shortage Area (HPSA) &
Physician Scarcity Areas (PSA)

10. 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:

11. 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 is listed as physical therapy and therefore will go towards any deductibles first before paying

12. 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)

13. 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

14. 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

15. 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

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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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)

25. 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

26. Diabetic Foot & Ankle Care, Peripheral Neuropathy: Neurological Evaluation (Measure 126)
Patient must be 18 or older
CPT to qualify for measure:
– 11044
– 11057
– 11721
, 97598
– 99205
– 99215
Use CPT G8404 to report this measure

27. Diabetic Foot & Ankle Care, Ulcer Prevention: Evaluation of Footwear (Measure 127)
Patient must be 18 or older
CPT to qualify for measure:
– 11044
– 11057
– 11721
, 97598
– 99205
– 99215
Use CPT G8410 to report this measure

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

29. 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

30. 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

31. 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

32. 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

33. Thank You!!