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A CMS Contracted Intermediary and Carrier

Education Makes the Difference

Education Makes the Difference

Education Makes the Difference

J4 A/B MAC Local Coverage Determinations (LCDs)

Provider Outreach and Education

Published January 2008

J4 MAC A/B Contact Information

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Questions or concerns about the Jurisdiction 4 (J4) Medicare Administrative Contractor (MAC) A/B implementation process can be e-mailed to:

[email protected]

Slide 2

Today's Objectives

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· Discuss Local Coverage Determination (LCD) basics. · Review the J4 MAC A/B LCD consolidation process. · Discuss cutover dates and when each segment should begin utilizing the J4 MAC A/B LCDs. · Navigate the J4 MAC LCD and TrailBlazer LCD Web sites via live Internet.

Slide 3

Statutory Basis for Developing LCDs

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According to Section 1862(a)(1) of the Social Security Act, CMS and its contractors may develop standards outlining what is "reasonable and necessary" for coverage under Medicare. This can include specific qualifications applicable to providers seeking Medicare coverage of certain procedures. Section 522 of the Benefits Improvement and Protection Act (BIPA) created the term "local coverage determination."

Slide 4

LCD Basics

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· In the absence of national policy, Medicare contractors may establish medical policy. · TrailBlazer's LCDs consist only of "reasonable and necessary" information. They do not include benefit category and statutory exclusion provisions or coding instructions.

Note:

LC Ds

TrailBlazer uses a separate, but related article that communicates information such as coding instructions and reasons for denial of payment.

Slide 5

TrailBlazer's Definition of `Reasonable and Necessary'

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Slide 6

LCD Basics

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· TrailBlazer does not develop an LCD for every service or procedure that is covered. · Absence of an LCD does not mean non-coverage for a service or procedure that fits a Medicare benefit category. It means that currently TrailBlazer has not identified the service(s) as requiring a local policy. Nevertheless, Medicare relies on providers to report services appropriately so payment is made only for services that meet the general definition of "medically reasonable and necessary."

Slide 7

LCD Basics (Cont.)

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· Services for which payment by Medicare is sought must be: Performed in accordance with federal laws, regulations and Medicare national payment rules. Performed in accordance with Medicare coverage policies (national and local). Performed by a qualified practitioner. Performed for a qualified beneficiary. Medically reasonable and necessary. Coded correctly.

Slide 8

Why Have LCDs?

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TrailBlazer develops LCDs to: · Manage payment errors (overutilization and incorrect utilization). · Ensure proper utilization of new technology. · Help ensure consistency within the TrailBlazer service areas. · Implement a Least Costly Alternative (LCA). Also, LCDs allow TrailBlazer to auto-deny payment for specified services based on these policies. Use of LCDs to automate claim payment is high priority for TrailBlazer contractor medical directors. Slide 9

LCD Basics

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· TrailBlazer may develop LCDs pertinent to its areas of jurisdiction. · TrailBlazer generally addresses components of Part A and components of Part B in a single LCD. · The only time an LCD specific for Part A or Part B is developed is when the service is not covered in one of the areas (e.g., partial hospitalization psychiatric programs (Part A only) or chiropractic services (Part B only). · TrailBlazer maintains all LCDs on its Web site and in the Medicare Coverage Database (MCD). · LCDs are developed according to CMS guidelines.

Slide 10

LCD Basics (Cont.)

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· Newly developed LCDs and those with significant revisions are posted for "comment" for 45 days on the Draft page of the TrailBlazer Web site. · All comments are considered as the LCD is finalized. · Once finalized, a synopsis of the LCD is published in a TrailBlazer newsletter. · Approximately 45 days after it is finalized, the LCD becomes effective.

Slide 11

LCD Elements

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· Familiarity of an LCD helps providers and their billing staffs gain a full understanding of the payment/denial of a service. · TrailBlazer encourages providers, billing personnel and others who may be responsible for filing claims to Medicare to be cognizant of all information contained within an LCD. · There are many components that comprise an LCD.

Slide 12

LCD Elements (Cont.)

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The information that may be contained in an LCD includes: · Indications and limitations of coverage and/or medical necessity. · CPT/HCPCS codes. · ICD-9-CM codes that support medical necessity. · Utilization guidelines. · Documentation guidelines. · Drug wastage. · Individual consideration guidelines, if applicable.

Slide 13

Helpful Tips

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· Printing LCDs is not recommended. LCDs change often. When a printed version is utilized as a desk reference, providers run the risk of using out-of-date information. · Review LCDs carefully and completely. · Since many diagnosis codes are listed within a range of codes, for better results in searching for a specific code, use the "core" of the code rather than the complete code (e.g., core of 093.20­093.24 is 093). After completing the search, scroll through the section of codes to determine if the specific code you are looking for is included in the LCD.

Slide 14

J4 MAC A/B LCD Consolidation Process

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MACs are required to consolidate existing LCDs of the outgoing carriers/intermediaries within their jurisdictions. CMS required TrailBlazer to complete the consolidation of LCDs prior to the cutover of the first segment within the J4 jurisdiction and early enough to allow a minimum 45-day notice period.

Slide 15

J4 MAC A/B LCD Consolidation Process (Cont.)

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The analysis of all LCDs in J4 began very early in the implementation to determine their applicability jurisdictionwide. In consolidating the LCDs, TrailBlazer was required to select the least restrictive LCD from the existing LCDs on a single topic and consolidate the active edits in the system.

Note: In accordance with CMS' instructions, absence of policy in any one jurisdiction did not make that the "least restrictive." (There are some occasions where no policy previously existed (Oklahoma Part A). Now a policy will exist.)

Slide 16

J4 MAC A/B LCD Consolidation Process (Cont.)

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TrailBlazer compared more than 800 LCDs from: · · · · TrailBlazer (Part A and Part B). Noridian (Colorado). Chisholm (Oklahoma). Pinnacle (New Mexico and Oklahoma).

The consolidation resulted in 138 LCDs, many of which contain coverage provisions that are new in some way to TrailBlazer.

Slide 17

J4 MAC A/B LCD Consolidation Process (Cont.)

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· LCDs are "date-of-service-driven." · Claims received by TrailBlazer after cutover with service dates prior to cutover will be adjudicated using the previous contractor's policies. · Claims received by TrailBlazer after cutover with service dates after the cutover will be adjudicated using the J4 LCDs.

Slide 18

Important Dates

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LCD effective dates of service according to each segment's cutover: March 1, 2008 New Mexico Part B Oklahoma Part A and Part B Colorado Part B

March 21, 2008

June 13, 2008

Colorado Part A New Mexico Part A Texas Part A and Part B

Slide 19

What Elements Were Considered?

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· Indications and limitations: Description of the service/procedure. Under what circumstances is it considered medically necessary? Description of any credentialing or accreditation requirements of the providers of the service/procedure. Description of any limitations to the service/procedure put in place. · CPT/HCPCS codes.

Slide 20

What Elements Were Considered? (Cont.)

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· ICD-9-CM diagnosis codes: Comparison of codes included in each LCD. Their consistency with the stated indications and limitations. Their use of dual diagnosis requirements or secondary diagnoses, when applicable. · Utilization and documentation guidelines: Comparison of frequency limitations, if any. Comparison of documentation required to support the LCD's indications and limitations. · Coding guidelines: Compared and included in the LCD's related article.

Slide 21

Sources of Information and Basis for Decision

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Providers can find information on how the consolidation decision was made or what other LCDs were evaluated in developing the consolidated LCD in: · "Sources of Information and Basis for Decision" section of the LCD in: J4 (CO, NM, OK, TX) MAC integration LCDs. Or, Other contractor LCDs.

Slide 22

Important Reminders

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· CMS reviewed and approved the consolidated LCDs now posted on the J4 MAC Implementation site. · There was no formal comment period for these consolidated policies. The LCDs were posted on the J4 MAC Implementation site for the 45-day "notice period" December 20, 2007. · TrailBlazer will review and consider all comments received despite there being no formal comment period.

Slide 23

Important Reminders (Cont.)

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· We encourage outgoing contractor providers and their billing staffs to review the LCDs thoroughly in order to gain a complete understanding of any changes. · If TrailBlazer missed an important issue regarding a least restrictive clause, comments are welcome and will be considered.

Slide 24

LCD Contact Information

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Providers may submit questions regarding LCDs/policies via e-mail to: [email protected]

Slide 25

Listserv Subscriptions

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We encourage providers to register for the J4 MAC Implementation News listserv, as well as the state-specific listserv for their service area from the J4 MAC Web site at: http://www.trailblazerhealth.com/J4 Providers receive the latest information and detailed explanations of ongoing J4 MAC implementation activities and all new process updates or changes.

Slide 26

Listserv Subscriptions (Cont.)

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Jurisdiction-wide information will be shared in the J4 MAC Implementation News listserv as often as is needed, with state-specific information included in the state-specific listservs.

Slide 27

Education Makes the Difference

Education Makes the Difference

Education Makes the Difference

Slide 28

A CMS Contracted Intermediary and Carrier

Education Makes the Difference

Education Makes the Difference

Education Makes the Difference

J4 A/B MAC Local Coverage Determinations (LCDs)

Thank you for attending.

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