Living with LCDs
By Alexander Miller, MD, FAAD, June 1, 2016
Medicare Administrative Contractor (MAC) Local Coverage Determinations (LCDs) exist for the purpose of defining coverage, billing, and documentation criteria for a variety of defined diagnoses or procedures. You most likely know that they exist, and you try to adhere to their directives. But do you really? If you receive a chart audit request focused upon specific services that you provided will you be able to justify what you did based upon fulfillment of LCD criteria, including documentation and signature?
The most prevalent LCDs affecting dermatologic care are for removal of benign lesions, actinic keratoses (AKs), and Mohs surgery. You may extract listings of LCDs pertinent to your practice from your MAC’s website. What if your MAC has no LCDs touching upon what you do? That does not mean that no policies regarding benign lesions, AK treatments, and Mohs surgery exist. In such instances the MAC simply does not feel a need to codify policies in an LCD. For example, despite a lack of LCDs for benign lesions, AKs, and Mohs surgery in the National Government Services (NGS) jurisdiction, which covers New York and all states north, you are expected to adhere to general coverage and documentation requirements, and to specific Mohs documentation criteria as delineated by the Centers for Medicare and Medicaid Services (CMS). Furthermore, you should carefully observe Medicare guidelines on non-covered services. Specifically, the Medicare Benefit Processing Manual, Chapter 16, Sec. 120 states: “Cosmetic surgery or expenses incurred in connection with such surgery is not covered. Cosmetic surgery includes any surgical procedure directed at improving appearance, except when required for the prompt (i.e., as soon as medically feasible) repair of accidental injury or for the improvement of the functioning of a malformed body member.”
The treatment of AKs is covered nationally by Medicare under national coverage determination 250.4. However, that does not allow for imprecise documentation. Noridian Healthcare Solutions (NHS), the MAC which administers Medicare claims processing for the western United States including Alaska and the Pacific Islands, has an LCD for AKs. The LCD mandates the following minimum documentation requirements: the method of destruction/removal should be listed; the number and location of the AKs should be described. The LCD goes on to state the following: “When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary.” The practical corollary of this statement is that if your patient record lacks the minimum documentation criteria for treated AKs your claim will be denied if audited.
Documentation for Mohs surgery must follow LCD edicts, particularly since lapses in documentation may result in post-payment claim rejections and demands for refunds. If faced with an audit of Mohs surgery chart material you should ensure that present and future documentation adheres to the criteria set forth in the LCDs. For example, both the First Coast (FCSO) (Florida and Puerto Rico) and Novitas (Texas and surrounding states and New Jersey and adjoining states except for New York) Mohs LCDs list extensive documentation requirements. Among these are: a description of why a lesion was not managed with non-Mohs surgical techniques such as excision or destruction; why Mohs is an appropriate choice; why a complex flap or graft is done. A discussion of treatment options must be documented. The chart must also specify that the Mohs physician is both a surgeon and pathologist. Upon audit, charts lacking the details called for in the documentation requirements section will likely lead to a demand for a refund even if an otherwise perfectly legitimate Mohs surgery was done.
The Novitas Mohs surgery and Benign Skin Lesion LCDs contain the following ominous declaration: “Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.” What does this mean? Being a statistical outlier may get you audited.
Example 1: Your California Medicare patient implores you to remove multiple seborrheic keratoses because they are “ugly,” catch on clothing, and are a nuisance. You freeze 11 keratoses and bill Medicare CPT 17110, destruction of up to 14 benign lesions, and ICD-10 L82.0, inflamed seborrheic keratosis.
Answer: Incorrect. Ugly, catching on clothing, and nuisance do not fulfill the Jurisdiction E and F Noridian MAC Benign Skin Lesion LCD criteria. In order to be covered, a seborrheic keratosis would have to exhibit one or more of the following: bleeding, intense itching, pain, inflammation (purulence, oozing, edema, erythema), obstruction of an orifice or restricting vision, or be subject to recurrent physical trauma. Any of the qualifying criteria would need to be clearly documented in the patient record. A chart review by the MAC or other designated reviewer could lead to unpleasant consequences for the physician if a pattern of inappropriate billing were uncovered. However, if the chart record were to specify that the seborrheic keratoses that caught on clothing were painful, inflamed, or bleeding, then they would meet coverage criteria.
Example 2: A Medicare patient with a recently excised perinasal basal cell carcinoma complains of a reduction of air flow through the right naris and a traction deformity of the ala. You correct the deformity and open the naris with a V-Y release surgical procedure. As the surgery is related to the previous basal cell carcinoma, you bill Medicare CPT 14040 for the V-Y adjacent tissue rearrangement.
Answer: Correct. The surgery was done as a consequence of a previous treatment for a medically necessary service to treat the malignancy, and as such constituted an extension of the malignancy’s treatment. Furthermore, the procedure was done to improve the function of a deformity. The surgery therefore constituted a covered service. The Medicare Benefit Processing Manual allows for coverage when a surgery done for therapeutic purposes “also serves some cosmetic purpose.”
Example 3: You freeze nine actinic keratoses on a Medicare patient’s face and bill your Noridian contractor CPT 17000 and 17003x8 for your efforts. Your chart record specifies that the AKs were on the face and that they were destroyed with liquid nitrogen cryotherapy.
Answer: Incorrect. The Noridian Actinic Keratosis LCD (L34188) requires a description of the number and locations of the lesions. The description may be in the form of a photograph or drawing. In this particular case the chart did not accurately list the locations of the lesions beyond that they were located on the face. This imprecision may be used by an auditor as grounds for rejecting the claim.
Example 4: You receive a request for submission of several Mohs surgical chart files for review by your MAC. You are confident that you have satisfied all of the documentation requirements for the surgeries and ask your staff to submit the chart materials for audit. To your major surprise you receive a demand for a refund of all of the payments for the Mohs surgeries. How could that be? You were sure that your record keeping adhered perfectly to the LCD requirements.
Answer: You most likely neglected to submit one universally required detail: your legible signature. Lack of signature attestation is the number-one reason for rejection of reviewed claims. Medicare requires that a signature be appended to the chart entry and that the signature be legible. An electronic health record must appropriately attest to the authenticated signature. Otherwise, you may submit a signature attestation statement, downloadable from the MAC website, for each chart. Alternately, if the signature is not legible, attach a signature log listing the date, name, signature, initials, and degree of the treating physician or health professional.
