Orthopedic Coding Alert

NCDs and LCDs can light the path to a clean claim New coders soon learn that there is more to coding than merely selecting an appropriate number from the ICD-9 or CPT manuals. They quickly come face-to-face with a series of obstacles that perhaps no one in their training courses has shared. Collectors in the office may introduce these obstacles when a payer denies a claim for "medical necessity." Whatever way it happens, coders learn quickly that there are various tools that need to be included in their "coding toolbox." Two important coding tools include the knowledge of payer coverage policies and payer reimbursement polices. Understanding how to use these different policies can turn an average coder into a valuable resource for the provider. Here are the details. Access NCDs for Coverage Insights Coverage policies, also known as medical polices, detail various procedures that carriers have determined to be "misunderstood" or potentially abused. These policies include carriers- research into clinical information from medical societies regarding what the procedure is for and how it's done. The policies also list the applicable CPT codes for the services along with ICD-9 codes that indicate medical necessity. Unless the submitted service in the article has a linked diagnosis from the policy, the carrier will likely deny the claim. Under certain circumstances, you can appeal a denied claim with other information and documentation. On the other hand, the likelihood of overturning a denial based on medical necessity will depend on carrier rules and interpretation of the procedure performed, and the payer will measure your procedure's necessity against the coverage policy. CMS has a number of these policies called NCDs or national coverage determinations. These polices are often interpreted, cited and referred to by the regional Medicare offices (carriers and fiscal intermediaries) and serve as the basis of the LMRP (local medical review policy) now known as the LCD (local coverage determination). You can find these both on the CMS Web site under NCD or on the local or state Medicare Web site under the LCD. You can find an example of an NCD policy (for osteogenic stimulators for bone regeneration to aid in bone fracture healing) here: http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=150.2&ncd_version=2&basket=ncd%3A150%2E2%3A2%3AOsteogenic+Stimulators. Don't Assume Medicare Has the Only Policies Insurance carriers like Aetna, Blue Cross, UnitedHealthcare, Cigna and Humana also have coverage determinations for some procedures, and you can find these on their respective Web sites. Unfortunately, however, some carriers require that you obtain a password before they allow you to view the policies. But over the years, carriers have become more open about their edits and medical policies. Important: As a side note, sometimes payer contracts and patient coverage plans will have special carve-outs to include special [...]