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NORIDIAN MEDICARE
CURRENT FINAL POLICIES (LCDs, formerly LMRPs)

as of: 4/2008
Contractor
Determination
Modified
Application of Bioengineered Skin Substitutes.
Injections- Tendon, Ligament, Ganglion Cyst,Tunnel Syndromes and Morton's Neuroma (formerly Non-Malignant Skin Lesion Removal) Symptomatic Pathological Nail and Its Treatment Treatment of Ulcers and Symptomatic Hyperkeratoses Treatment of Varicose Veins of the Lower Extremity LCDs REGARDING DMEPOS
www.noridianmedicare.com/dme/coverage/lcd.html
Therapeutic Shoes for Persons with Diabetes NATIONAL COVERAGE DETERMINATIONS (NCD)
Access via: www.noridianmedicare.com/p-medb/
Consultation Services by a Podiatrist in a SNF Electrical Stim and Electromagnetic Tx of Wounds Neuromuscular Electrical Stimulation (NMES) Non-Contact Normothermic Wound Therapy (NNWT) Physician's Office within an Institution- Supplies Porcine Skin and Gradient Pressure Dressings Prolotherapy, Joint Sclerotherapy, and Sclerosing Inj Sensory Nerve Conduction Threshold (sNCTs) Tx of Motor Function Disorders with Elec Stim NORIDIAN MEDICARE COVERAGE POLICIES
SYMPTOMATIC/PAINFUL SKIN LESIONS
as of : 4/2008
Relevant Noridian Medicare LCDs:
Skin Lesion (Non-Melanoma) Removal (L10106) Tx of Ulcers & Symptomatic Hyperkeratoses (L23770) Qualifying Criteria (abbreviated, and edited):
Bleeding, intense itching, or painPhysical evidence of inflammationUncertain clinical diagnosis (e.g., pigmented lesion)Anatomic region subject to recurrent physical traumaVerrucae/ warts (under same criteria as above) Representative types of lesions:
Moles, nevi, painful hyperkeratotic lesions, porokeratoses, keratoderma, verrucae Select CPT code based upon method of Tx
PARING OR CUTTING (implies thinning, without removal?)
Special Diagnosis codes for use of CPT 11055-57 series:
PRIMARY DIAGNOSIS
700
Corns and Callouses (suggest ONLY use this for RFC) Acquired Keratoderma (Suggested for Symptomatic Lesions) Other Specified Congenital Anomalies of Skin SECONDARY DIAGNOSIS (must have one)
686.9
Local Inflammation/infection of Skin and Subcutaneous Tissue SHAVING ("Shave Removal"?)
DESTRUCTION inc acid, chemo, cryo, laser, currettement, etc
EXCISION
implies full thickness excision and closure via suture
diam 0.5 cm or less in "excised diameter" NOTE: as of CPT 2003, "diameter" inc widest dimension oflesion itself, PLUS excised margins QUALIFYING DIAGNOSIS CODES
STAND-ALONE DIAGNOSES (do not require secondary Dx)
78.19 Verruca; wart238.2 Skin Neoplasm of Uncertain Behavior686.1 Pyogenic Granuloma of Skin or Subcut Tissue701.1 Keratoderma, acquired (Indicates symptomatic, painful or inflamedIf NOT symptomatic, use 700, and refer to RFC) NON-STAND-ALONE DIAGNOSES (DO require secondary Dx)
216.7 Benign Neoplasm of skin, lower extremity701.9 Unspecified Hypertrophic and Atrophic Skin SECONDARY DIAGNOSES (for NON-STAND-ALONE Dx)
Specified Local infections of Skin and Subcutaneous Tissue Other specified erythematous conditions (e.g. intertrigo) Noridian Medicare policies: Symptomatic/Painful Skin Lesions NORIDIAN MEDICARE COVERAGE POLICIES
INJECTIONS
as of: 4/2008
Relevant Noridian Medicare LCDs:
Injections- Tendon, Ligament, Ganglion Cyst,Tunnel Syndromes and Morton's Neuroma (L23856) Blocks and Destruction of Somatic and Sympathetic Nerves (L23692) NOTE: Discussion is ongoing with Noridian Medicare regarding
correct coding for injection of peripheral nerves
There are expected to be 2 new codes in CPT 2009 to reflect injection of
interdigital neuroma
Correspondingly, for now, listing of applicable codes is separated
Noridian Medicare vs "all others", where applicable
STRUCTURE INJECTED
NORIDIAN
MEDICARE
Ligament or Tendon Sheath, Plantar Fascia Joint or Bursa, small (distal to LisFranc) Joint or Bursa, Intermed (LisFranc and prox) Peripheral Nerve-other than Tarsal Tunnel or "Morton's Neuroma" "Morton's Neuroma" (any interdigital neuroma) Sclerosing Injection (alcohol or neurolytic agent) of nerve * for Noridian Medicare, insert "tarsal tunnel" or "Morton's Neuroma" in Item 19 of CMS 1500 form No more than 2 injections per date of service Medically necessary imaging guidance (i.e. fluoroscopy, ultrasound) is separately billable (should be rarely medically necessary)fluoroscopic guidance INJECTED SUPPLY IS SEPARATELY BILLABLE VIA HCPCS CODES
dexamethasone sodium phosphate (Dalalone, Decadron) methylprednisolone sodium succinate (Solu Medrol) Local anesthetics (lidocaine, marcaine, etc.) are NOT billable USE APPLICABLE MODIFIERS TO REFLECT SEPARATE SITES, ETC.
/Noridian Medicare policies - injections NORIDIAN MEDICARE COVERAGE POLICIES
CASTS, SPLINTS, UNNA BOOTS
as of: 4/2008
Relevant Noridian Medicare LCDs:
BACKGROUND
The initial application of any cast, splint, or unna boot is included
in the global allowance for virtually every procedural service
(inc injections, debridement, etc.)
Noridian Medicare limits coverage of supply for casts, splints and braces to: Fractures and DislocationApplication of a cast may be covered for other diagnoses, suggestion, for Medicare patient w/ sprains, etc.use a BRACE Application of the cast or splint is separately billable from the materials used Application of an unna boot includes the material used Medicare currently uses "Q" codes to reflect cast supply reimbursed according to a fee scheduleweblink to all Q codes, fee schedule: Non-Medicare payers use standard HCPCS supply codes CAST APPLICATION CODES
Application of short leg (below knee to toes) cast, non-weightbearing Application of short leg (below knee to toes) cast, walking Application of walker to previously-applied cast Application of clubfoot cast, inc manipulation CAST REMOVAL OR REPAIR
Cast removal is only billable if the cast was applied by another CAST SUPPLY
NON-MEDICARE
MEDICARE
Cast supply, short leg cast, adult, plaster Cast supply, short leg splint, adult, plaster Weblink to noridian Medicare Q codes noted above UNNA BOOT
Covered for arterial or venous dermatitis, with ulcerationALSO covered for sprains and strains of ankle, foot , or toesNOT covered for fractures, dislocations, edema, post immobilizationNOT covered for phlebitis or edema or varicose veins without ulcerationNOT covered for tendonitis WALKING BRACES, ETC
Gradient compression stocking 30-40 mm Hg, each Gradient compression stocking 40-50 mm Hg, each The allowance for braces etc includes fitting and adjustment GLOBAL FRACTURE CARE
The global service for fracture care (or surgery) includes the initial cast application; Medically necessary subsequent x-rays, cast applications and supplies are separately billable- even within the (Medicare 90 day) global period CMS 21 PROVIDER STANDARDS FOR DISPENSING DME, ETC:
http://www.palmettogba.com/palmetto/other.nsf/PrintableDocs/85256D430058D01D85256B830076C61D
Noridian Medicare policies - casts NORIDIAN MEDICARE COVERAGE POLICIES
WOUND CARE
as of: 4/2008
Relevant Noridian Medicare LCDs:
Tx of Ulcers and Symptomatic Hyperkeratoses (L23770)Unna Boots (L23791)Application of Bioengineered Skin Substitutes (L23684)Non-Invasive Peripheral Arterial Studies (L23741)Non-Invasive Peripheral Venous Studies (L23743)Tx of Varicose Veins of the Lower Extremities (L23902) Coding and Qualifying Criteria for this Subject are extremely complex;Providers must carefully independently review, and should/must trust what manufacturers say SHARP DEBRIDEMENT
Select CPT code based upon DEPTH of SHARP debridement
Code is determined by depth of DEBRIDEMENT, NOT depth of the Ulcer
Use of whirlpool, flush, spray or chemical debridement are NOT applicable here
(use physical therapy or E/M codes)
Medicare
Global Days
skin, subcutaneous tissue, muscle, and bone QUALIFYING DIAGNOSIS CODES
Atherosclerosis of lower extremity, with ulceration Atherosclerosis of lower extremity, with gangrene Varicose veins of lower extremity, with ulcer Varicose veins of lower extremity, with ulcer and inflammation Unspecified local infection of skin and subcut tissue Decubitus ulcer, other than ankle or heel Neurogenic or trophic ulcer, Heel and/or midfoot Neurogenic or trophic ulcer, other, inc toes Multiple and unspecified open wounds, complicated APPEND APPLICABLE MODIFIERS TO DESCRIBE AREAS INVOLVED
APPLICATION OF UNNA BOOTS, OR CASTS AFTER WOUND DEBRIDEMENT
CPT considers the first cast or splint applied the same day as a procedure to be included in the global procedural service As such, Medicare will not pay for application of an unna boot, cast, or total contact cast on the same day as any procedural (e.g. wound debridement) service If it's a separate site, bill the cast application with a "-59" modifier UNNA BOOTS
Covered as primary dressings. As such, covered in the management of ulcerations with or without inflammation due to venous insufficiency,as well as immobilization of ligamentous injuries (sprains) of the ankle, foot, and toesThey are NOT covered (under Medicare) for: fractures, dislocations, edema, venous insufficiency without ulceration, phlebitis, edema, varicose veins without ulceration, tendonitis, ischemic ulcers, neuropathic ulcers (i.e. no open wound) UNNA BOOTS
COVERED DIAGNOSES FOR UNNA BOOT
440.23
Atheroclerosis of lower extremity, with ulceration Varicose veins of lower extremity, with ulcer Varicose veins of lower extremity, with ulcer and inflammation Postphlebitic syndrome with ulcer and inflammation ** NOTE: NOT covered for debridement Neurogenic or trophic ulcer, Heel and/or midfoot Neurogenic or trophic ulcer, other, inc toes OTHER DRESSINGS, MATERIALS AND SUPPLIES
Any and all dressings, materials and supplies used in the physician's officeare included in the debridement, and NOT separately billable Dressings, materials and suppplies provided to the patient forat-home use are billable with applicable HCPCS codes QUALIFYING CRITERIA FOR BIOENGINEERED SKIN SUBSTITUTES
Diabetic Neuropathic Ulcers
of greater than 4 weeks durationMust have failed to respond to at least one month of conservative TxMust be partial or full-thicknessMust be free of infection of skin and boneMust have adequate circulation Must evidence appropriate steps to off-loadMust document measurements of ulcer on initial presentation, at end of conservative Tx, and at beginning of Wound Care Tx Must document "surgical fixation" (steri strip, etc.) Venous Stasis Ulcerations
of greater than 3 months durationMust have failed to respond to at least two months of conservative TxMust be partial or full-thicknessMust document measurements of ulcer on initial presentation, at end of conservative Tx, and beginning of Wound Care Tx PREPARATION FOR APPLICATION OF BIOENGINEERED SKIN SUBSTITUTE
Site preparation via sharp debridementNO site preparation is billable on same date as Apligraf or Oasis/Surgisis APPLICATION OF BIOENGINEERED SKIN SUBSTITUTE
Must state in documentation that graft is "surgically fixated"15170 Acellular Dermal Replacement, leg (Integra, Graftjacket) Allograft Skin for Temporary Wound Closure, leg (cadaveric) Acellular Dermal Allograft, leg (AlloDerm) Tissue cultured Allogeneic Skin Substitute, up to 25 sq cm (Apligraf) Tissue cultured Allogeneic DERMAL Substitute, leg (Transcyte, Dermagraft) Xenograft (Dermal) Skin for Temp Wound Closure, leg (Mediskin, EZ Derm) Acellular Xenograft Implant (Oasis, Surgisis)15430 has a 90 day global (Medicare) BILLING FOR BIOENGINEERED SUPPLY
Tissue Cultured Allogeneic Substitute (Apligraf, Transcyte), per sq cm Acellular Xenograft Implant (Oasis, Surgisis), per sq cm Dermal (but NOT epidermal) tissue; per sq cm (Dermagraft) Non-metabolically activedermal/epidermal tissue; per sq cm (Integra) Non-metabolically active tissue (FOR HOSP USE?) WOUND CARE OTHER THAN VIA SHARP DEBRIDEMENT
SELECTIVE
Intended to be used by physical therapists Intended to be used by physical therapists Intended to be used by physical therapists NEGATIVE PRESSURE WOUND THERAPY
Total wound surface less than 50 sq cm; per session Total wound surface greater than 50 sq cm ELECTRICAL STIMULATION
Electrical stimulation of wound (unattended)They do not reimburse for the device (E0761) ELECTROMAGNETIC THERAPY OF WOUND
HYPERBARIC OXYGEN (TOTAL BODY)
Physician attendance and supervision of HBO BILLING SUPPLIES TO DMERC
Most common reasons for denial of billing for Wound Care Supplies Incorrect Place of Service (should be "home"- Not "office"Lack of UPIN number of referring physicianLack of Code "A" modifier number, indicating number of woundsLack of documented medical necessity HCPCS CODES AVAILABLE ONLINE
CMS "21 PROVIDER STANDARDS" FOR DISPENSING DME, ETC
http://www.palmettogba.com/palmetto/other.nsf/PrintableDocs/85256D430058D01D85256B830076C61D
c: Noridian Medicare policies: wound care NORIDIAN MEDICARE COVERAGE POLICIES
ROUTINE FOOT CARE
as of: 1/2006
Relevant Noridian Medicare LCDs:
NOTE: "Routine Foot Care" reflects the debridement or trimming of asymptomatic corns, callouses, and nails.
In the absence of underlying "risk status", it is a non-covered service In the presence of "at-risk" status, it is a covered service Noridian Medicare currently has an extremely narrow interpretationregarding what constitutes "sufficient risk" In the presence of symptoms (pain, inflammation, hemorrhage, infection, etc),it is NOT "routine foot care", and should not be documented or coded as such Non-Malignant Skin Lesion RemovalTx of Ulcers and Symptomatic Hyperkeratoses Many visits may contain elements of BOTH routine and Non-routine services.
Be sure to document and code accordingly Noridian Medicare has rules regarding "incident to" services These services are only payable if performed by the physicianThese services are not payable by Medicare if delegated to staff, etc. APPLICABLE ROUTINE FOOT CARE SERVICES
These are the ONLY applicable CPT codes for Routine Foot Care COVERED DIAGNOSES (IN ADDITION TO RISK)
Dystrophic nailThere is no diagnosis code to reflect an elongated nail; use risk Dx only NORIDIAN MEDICARE ROUTINE FOOT CARE RISK DIAGNOSES
as of: 2/2005
Active Description
Required
Required
Hereditary/idiopathic peripheral neuropathies Acute polyneuritis, polyneuropathy in collagen vascular disease Polyneuropathy in diabetes, malignancy, and other diseases Polyneuropathy due to alcohol, drugs, and other toxic agents Thromboangiitis obliterans (Buerger's Disease) Q MODIFIERS
non-traumatic amputation of all or portion of a foot (Requires 2 or more)
Absent posterior tibial pulse
Absent dorsalis pedis pulse
Advanced trophic changes (3 required)
decrease in hair growthnail thickeningdiscolorationthin or shiny skin texturereddened skin color (rubor) (Requires 1 Q8 and 2 Q9 findings)
Claudication
Temperature changes (e.g., cold skin)
Edema
Abnormal spontaneous sensations in the feet
Burning
Noridian Medicare policies- routine foot care NORIDIAN MEDICARE COVERAGE POLICIES
ULCERS AND ULCEROUS LESIONS
as of 4/2008
Relevant Noridian Medicare LCDs:
Tx of Ulcers & Symptomatic Hyperkeratoses (L23770)Skin Lesion (Non-Melanoma) Removal (L10106)Unna Boots (L23791)Surgical Dressings (A23903)Tx of Varicose Veins of the Lower Extremities (L23902) QUALIFYING CRITERIA (abbreviated and edited):
Must have a minimum partial thickness loss of epidermisNo "pre-ulcerous" or Wagner Grade 0 lesionsMust be "true ulcers"- not impending or potential Circumscribed Dermal InfectionsConditions affecting contiguous deeper structuresDebridement of ground-in dirt from abrasions Code is determined by depth of DEBRIDEMENT (as performed and documented),
NOT depth of the ulcer
Select CPT code based upon DEPTH of SHARP debridement
No more than 4 services on one date of service; otherwise on appeal
Use of whirlpool, flush, spray or chemical debridement are NOT applicable here
(use physical therapy or E/M codes)
Medicare
Global Days
I&D of Abscess; Multiple or Complicated skin, subcutaneous tissue, muscle, and bone QUALIFYING DIAGNOSIS CODES
Atherosclerosis of lower extremity, with ulceration Atherosclerosis of lower extremity, with gangrene Varicose veins of lower extremity, with ulcer Varicose veins of lower extremity, with ulcer and inflammation Other specified skin and subcut infections Unspecified local skin infection/inflammation Ulcer of Heel and Midfoot (chronic, neuropathic) Ulcer of Other part of foot (chronic, neuropathic) Multiple and Unspecified Open Wounds, complicated Noridian will permit up to four independent debridements on same date of service APPEND APPLICABLE MODIFIERS TO DESCRIBE AREAS INVOLVED
UNNA BOOTS
Covered for arterial or venous dermatitis, with ulcerationAlso for sprains and strains of ankle, foot, or toesNOT covered for fractures, dislocations, edema, postop immobilizationNOT covered for phlebitis or edema or varicose veins without ulcerationNOT covered for Tendonitis OTHER DRESSINGS, MATERIALS AND SUPPLIES
Any and all dressings, materials and supplies used in the physician's officeare included in the debridement, and NOT separately billable Dressings, materials and suppplies provided to the patient forat-home use are billable with applicable HCPCS codes Noridian Medicare Policies: Ulcers and Ulcerous LesionsSEE ALSO: Noridian Medicare Policies: Wound Care

Source: http://www.wspma.org/resources/coding_suggestions.pdf