By Robert (Bob) Weiss, MS, LE Legislative Advocate
Status as of November 21, 2009
While Congress wrestles with the all-important issues of Medicare access and Medicare viability, the Centers for Medicare and Medicaid Services (CMS) continues its efforts to improve quality of care and reducing the cost of delivery of the quality care.
Unfortunately, many changes to Medicare policies have unintended consequences to the lymphedema patient.
CMS MEDCAC - Lymphedema Panel
On November 18, the CMS Medicare Evidence Development & Coverage Advisory Committee (MEDCAC) conducted a full-day forum on the evidence basis of lymphedema measurement and treatment at their quarterly meeting, the first time in their ten-year existence that this subject was discussed.
The National Lymphedema Network, in partnership with the Lymphology Association of North American (LANA) and the American Lymphedema Framework Project (ALFP), took a leadership position in organizing lymphedema medical experts from around the country to "focus on the quality of evidence surrounding the diagnosis and treatment of secondary lymphedema." Evidence was submitted to the Lymphedema Panel regarding evidence supporting commonly used lymphedema diagnosis and treatment protocols.
The open meeting featured a presentation of the Technology Assessment commissioned by the United States Department of Health and Human Services/Agency for Healthcare Research & Quality from McMaster University Evidence-based Practice Center, Hamilton, Ontario, Canada, followed by assessments by Stanley Rockson, MD, and Jane Armer, PhD, RN, FAAN. This was followed by scheduled public comments from 13 lymphedema experts from lymphedema and venous organizations.
NLN Medical Advisory Committee members Kathleen Francis, MD, Sheila Ridner, RN, PhD, and Paula Stewart, MD, CLT-LANA, (LANA board vice-president) provided scheduled public comments, as did Robert Weiss, MS. ALFP Director, NLN MAC member and LANA board member Jane Armer, RN, PhD, was one of two invited guest speakers, and Janice Cormier, MD, MPH, NLN MAC member and ALFP executive committee member, was an expert guest member of the MEDCAC Lymphedema Panel. The NLN (and LANA and ALFP) were well-represented at this meeting and provided valuable input to CMS. Messages were targeted and cohesive, and well represented the important issues in this field.
In the afternoon the Panel questioned the presenters and discussed the evidence with the goal of eventually voting on a number of issues concerning their confidence in the adequacy of the evidence to support coverage of individual measurement and treatment modalities.
An open vote seemed to indicate that the final assessment would be that there is at least intermediate confidence that CDT and CDT with adjuvant intermittent pneumatic compression produce clinically meaningful improved health outcomes for lymphedema patients.
The MEDCAC Lymphedema Panel will be publishing their final assessment, with all supporting evidence, on the CMS MEDCAC web site within 30 days. The assessment will presumably be used by the CMS Coverage & Analysis Group in future discussions of Medicare coverage of lymphedema diagnosis and treatment. There will be future opportunities for public and expert inputs into proposed Medicare coverage changes and we must continue to take advantage of these opportunities.
Review of Medicare - Lymphedema Pump Claims
The DME MAC, A Medical Review Department review of HCPCS code E0652 pump claims from June 1, 2009 through September 30, 2009 identified eight hundred sixty-five (865) claims of which 263 were denied and 534 were down-coded to a less costly alternative.
The top two reasons for denial were that the requested "segmented sequential pneumatic compressor with calibrated gradient pressure" was considered "not reasonable and necessary," and the "prescription is incomplete."
The results point up the importance of a well-written Certificate of Medical Necessity (CMN) DME MAC Form 04.04B /CMS Form 846 Pneumatic Compression Devices and a prescription showing that use of a multi-chambered sequential pressure pneumatic compressor with calibrated gradient pressure is medically necessary in treatment of lymphedema, that other "more conservative" protocols such as elevation, compression and exercise have been tried and have not been successful, and that there is a medical reason for this patient to have a pump because of difficulty in performing self-CDT at home, etc.
Episode Grouper Software
CMS is striving to find more efficient ways to manage medical care, and eliminate waste, duplication, and other inefficiencies. On November 10, Medicare conducted a "Listening Session" on "Defining an Episode Logic for the Medicare Physician Resource Use Measurement Program." The slide presentation, audio and transcript of phoned-in discussion can be found at www.cms.hhs.gov/center/physician.asp.
This writer called in to comment on the current implementation of DRGs (diagnosis-related groups) as a means of payment. Some of the lymphedema-related issues I raised included: inadequacy of ICD-9-CM and upcoming ICD-10-CM diagnostic codes in describing lymphedema; importance of grouping common co-morbidities such as cellulitis, CHF, chronic wounds, venous insufficiency, obesity, etc., since these affect the costs of a treatment episode; attribution to all members of the treatment team including the therapist; inclusion of all required DMEPOS whether Medicare-covered or patient paid in the cost of an episode; and capturing occurrences of recurring episodes of cellulitis.
Reopening Requests for Modifiers KX, GA, GZ and GY
Reopening Requests to add, change, or remove modifiers KX, GA, GZ, and GY will no longer be accepted for dates of claim receipt on or after December 1, 2009. To add, change or remove these modifiers, a Redetermination Request with proper documentation must be sent to the DME MAC Appeals Department, thereby forcing an automatic denial and an appeal.
Since these codes are meant to protect the Provider and Supplier from having to pay for a Medicare service which is likely to be denied, and requires the Beneficiary to pay in full up front for the medically required service or go without it, the burden of appealing the inevitable denial will fall on the Beneficiary.
DMEPOS Purchases from Medicare-Enrolled Suppliers
I have recently had two denials of compression garments on the basis that they were not provided by a Medicare-enrolled Supplier. This requirement has been on the books for many years, but is only recently being enforced as part of the upcoming DMEPOS Competitive Bidding Program, and the attempt by CMS to assure that suppliers of Medicare DMEPOS meet certain quality and financial requirements. When a Medicare Beneficiary with lymphedema buys a compression bandage kit, compression garment or device, it must be purchased from a Supplier who is enrolled as a Medicare Supplier if there is to be any chance for Medicare reimbursement.
The above comments are the opinions of a lymphedema patient advocate who is neither a physician nor a lawyer, and are not to be taken as medical or legal advice. Nor are the above comments meant as Medicare billing advice.
Robert "Bob" Weiss, M.S.
NLN LE Legislative Advocate