With 2018 come more CPT® and HCPCS code updates for podiatry care providers. While these changes and the myriad insurance requirements and coverage exceptions that come with them can feel overwhelming, a good practice is to start with a review of coverage determinations.
When it comes to Medicare, it’s important to know what’s covered and by how much, as in the case of routine foot care and orthotics. There may also be times when patients request services that Medicare does not cover, and understanding the processes put in place by the Centers for Medicare & Medicaid Services (CMS) can help podiatrists follow the proper procedures and ensure reimbursement.
Podiatry coding expert Lynn Anderanin recently discussed updates to podiatry policies and codes for 2018 in a live recorded event with ProfEdOnDemand that covers those processes and coverage determinations.
Which Podiatry Services Are Covered
Medical necessity is of course the key to the kingdom. Items or services that have already proven to be medically necessary are subject to either local coverage determinations (LCDs) or nationa l coverage determinations (NCD). Here’s a quick review of each:
- NCDs are issued by the secretary of the Department of Health and Human Services (HSS) and apply consistently across the country.
- LCDs are issued by a Medicare Administrative Contractor (MAC) and can be trickier since they apply only to the specific geographic region overseen by a particular MAC. The same service could be subject to different LCDs across the United States. As an aid, HCPCs and CPT® codes subject to LCDs are marked as such.
Timing Is Everything
Since there can be differences and changes among NCDs and LCDs, it’s important for podiatrists and coders to stay up to date before providing certain items or services to patients. If a patient requests an item or service not covered by an LCD or NCD, the service or item can still be provided, but either the physician or patient will have to foot the bill. If the physician wishes to bill the patient, an Advance Beneficiary Notice (ABN) must be issued before the item or service is provided.
Medically Necessary vs. Routine Foot Care
Figuring out when it’s appropriate to issue an ABN is an important point for podiatrists. This document should be issued if the item or service meets one or more of the following requirements:
- It is considered experimental or investigational.
- It is not considered safe or effective.
- It is statutorily excluded or does not meet the definition of any Medicare benefit.
- The patient has reached the maximum of amount of times Medicare will allow the item or service to be provided while granting reimbursement.
According to CMS, underlying conditions like Buerger’s disease, diabetes mellitus or chronic thrombophlebitis may necessitate foot care that would otherwise be considered routine, and therefore no ABN would be required. However, for patients without an underlying condition, there would be no proof that such care would be anything other than routine, and Medicare would not provide reimbursement.
Knowing Your Way Around ABNs
As soon as possible after the patient requests the item or service, the physician should issue the ABN and answer any questions the patient may have. Waiting until after providing the service to issue the ABN could mean the physician would be financially responsible. The ABN is a way to inform the patient that Medicare may not or will not provide reimbursement, and the patient would be responsible for paying for the item or service. The ABN must be issued with sufficient time for the patient to be able to make a well-informed decision.
On the form itself, the patient will select either Option 1 (indicating the physician should file a claim) or Option 2 (indicating no claim will be filed). Should the patient either refuse to sign, or initially sign and then change his or her mind, the physician must annotate the ABN, as patients aren’t able to refuse to sign and still request the item or service. Once the ABN has been signed, a copy should be given to the patient with another copy stored in the patient’s medical file.
Putting the Right Foot Forward with Proper Documentation
A proper understanding of LCDs and NCDs will help indicate when an ABN is necessary, and open conversations with patients will help clear up any confusion while also providing a better overall patient experience. By following proper CMS procedures, physicians can reduce administrative hassle while continuing to provide quality care for their patients.
