Knowledge Base Article

I try to write an article for the second Wednesday of the month newsletter about Medicare coverage policies and an article about Medicare contractors’ medical reviews for the third Wednesday. You may have noticed however, that these two topics are often intermingled. It brings to mind the age-old riddle – which came first, the chicken or the egg? Is a particular medical review based on the guidelines of a coverage policy or did the results of a review identify the need to develop a coverage policy? Actually, both scenarios occur, so sometimes it’s the chicken and sometimes the egg!

The December 2014 OIG Compliance Review of Ochsner Medical Center included the findings of a new issue not addressed in previous OIG compliance reviews. The issue is certain cochlear implant services did not meet the medical necessity requirements of the National Coverage Determination (NCD 50.3). As often is the case, the NCD requirements are extremely detailed. Cochlear implants are covered if the following conditions are met:

• Diagnosis of bilateral moderate-to-profound sensorineural hearing impairment
• Limited benefit from amplification (test scores of less than or equal to 40%)
• Cognitive ability to use auditory clues and a willingness to undergo an extended program of rehabilitation;
• Freedom from middle ear infection, an accessible cochlear lumen that is structurally suited to implantation, and freedom from lesions in the auditory nerve and acoustic areas of the central nervous system;
• No contraindications to surgery; and
• The device must be used in accordance with Food and Drug Administration (FDA)-approved labeling.
• Clinical trial services are covered for individuals meeting the selection guidelines above and with hearing test scores of greater than 40% and less than or equal to 60%.

The key to coverage criteria is not only must it be met, but it must be documented in the medical record in order to support that the service met Medicare’s coverage requirements. The OIG review found one patient whose hearing test score was 42% and one patient without a documented hearing test. These two errors resulted in an overpayment of over $56,000.

Another recent coverage decision with numerous detailed requirements is the Final Decision Memo for Lung Cancer Screening with Low Dose CT. This decision memo was released last Thursday (February 5, 2015). The eligibility criteria for screening include:

• Current smoker or one who has quit within the past 15 years
• Asymptomatic (no signs or symptoms of lung cancer)
• Age 55-77
• A 30-pack years smoking history (one pack-year = smoking one pack per day for one year)

In addition to the eligibility criteria, the decision memo lists detailed requirements for the order for low dose CT, including what it must contain, when it can be written, and the requirements for what a lung cancer counseling visit must include. There are also required criteria for the reading radiologist and the imaging facility. The details of the policy are quite extensive. Remember - although the effective date of the policy is February 5, 2015, it may be a while before CMS issues the official NCD and provides billing instructions. Medicare Administrative Contractors may not be ready to process these claims until the effective date of the forthcoming manualization of this decision.

One last update concerning NCDs - MLN Matters Article MM8954 provides guidance on the use of new HCPCS code G0276 for (Percutaneous Image-guided Lumbar Decompression (PILD) for Lumbar Spinal Stenosis (LSS)). Per this update, G0276 is to be used on and after January 1, 2015 only if the clinical trial is blinded, randomized, and controlled, and contains a placebo procedure control arm. Use procedure code 0275T for clinical trials for all PILD for LSS services for dates of service prior to January 1, 2015 and after January 1, 2015 for services not meeting the criteria for G0276.

So remember – after the chicken comes the egg – or is it, after the egg, comes the chicken?!? Whichever, but if there is a coverage policy, there may be a medical review in your future – so make sure you follow the criteria for cochlear implants, low dose CT lung cancer screening, and PILD for LSS and of course – document, document, document!

Updates of Local Coverage Determinations for last month include: