New Local Coverage Determinations with MAC Transition

on Tuesday, 05 May 2009. All News Items

This is a reminder that Cahaba GBA transitions from their role as the Fiscal Intermediary to the Medicare Administrative Contractor (MAC) for Alabama Part A on Monday, May 18, 2009.  As we have reported previously, there is little impact for Alabama Part A providers.  However, there are new Local Coverage Determinations (LCDs) for the MAC jurisdiction.

Cahaba has published a list of Part A LCDs that will replace the existing LCDs upon transition to the MAC.  Medical Management Plus has reviewed the new LCDs and compared them to the current Cahaba LCDs.  The new MAC Part A LCDs are for the same services that were covered by the existing LCDs.  Also, it appears the diagnosis requirements for all LCDs remain the same.  The only differences MMP identified in the new LCDs versus the current LCDs are:

  • The new LCDs do not list type of bill or revenue code requirements
  • The policy on Erythropoietin Analogues adds this bullet to the Utilization Guidelines – 
  • Effective 01/01/2008, CMS issued CR 5699, which instructs providers to report a hematocrit or hemoglobin for all non-ESRD anti-anemia claims, inclusive of ESAs. CR 5699 also instructs providers to report one of three modifiers (EA, EB or EC). The definitions of the modifiers are:
    EA: ESA, anemia, chemo-induced;
    EB: ESA, anemia, radio-induced and
    EC: ESA, anemia, non-chemo/radio.

For details regarding CR 5699, please see the Medicare Claims Processing Manual (PUB 100-04), Chapter 17, Sections 80.8, 80.9 and 80.10.

  • The policy on Zoledronic Acid adds the word “acute” to hypercalcemia of malignancy as an indication for treatment with Zometa®.  It also adds the term “post-menopausal” to senile osteoporosis as an indication for treatment with Reclast®.  The following limitations section was added to the Zoledronic Acid LCD:
    Limitations:

1. Zometa:
The safety and efficacy of zoledronic acid in the treatment of hypercalcemia associated with hyperparathyroidism or with other non-tumor-related conditions has not been established
2. Reclast:
Osteonecrosis of the jaw has been reported rarely in postmenopausal osteoporosis patients treated with bisphosphonates, including zoledronic acid. All patients should have a routine oral exam by the prescriber prior to treatment.

Medical Management Plus has tried to be thorough in our evaluation of the new policies.  However, there are a large number of policies and many policies are quite extensive with detailed information.  If there are particular policies that you are concerned about, we suggest you carefully review the new LCDs prior to the May 18 conversion date.  Here is a link to the Jurisdiction 10 LCD webpage: https://www.cahabagba.com/j10/lcds.htm

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