Thursday, September 10, 2015

ICD-10 Conversion/Coding Infrastructure Revisions/ICD-9 Updates to National Coverage Determinations (NCDs)--2nd Maintenance CR


This article is the second maintenance update of  ICD-10 conversions and coding updates specific to National Coverage Determinations (NCDs). The majority of the NCDs included are a result of feedback received from previous ICD-10 NCD CRs, specifically CR7818, CR8109, CR8197, andCR 8691. Links to related MLN Matters® Articles MM7818, MM8109, MM8197, and MM8691 are available in the additional information section of this article. Some are the result of revisions required to other NCD-
related CRs released separately that also included ICD-10.

Edits to ICD-10 coding specific to NCDs will be included in subsequent, quarterly updates. No policy-related changes are included with these updates. Any policy-related changes to NCDs continue to be implemented via the current, long-standing NCD process. Make sure that your billing staffs are aware of these spreadsheets attached to CR9087 for the following 13 NCDs:

NCDNCD Title
20.29Hyperbaric Oxygen Therapy
20.9.1Ventricular Assist Devices
50.3Cochlear Implantation
80.2Photodynamic Therapy
80.2.1Ocular Photodynamic Therapy (OPT)
80.3Photosensitive Drugs
80.3.1Verteporfin
110.1Intravenous Iron Therapy
150.3Bone (Mineral) Density Studies
160.18Vagus Nerve Stimulation
180.1Medical Nutrition Therapy
210.2Screening Pap Smears and Pelvic Examinations for Early Detection of Cervical or Vaginal Cancer
250.3Intravenous Immune Globulin for the Treatment of Autoimmune Mucocutaneous Blistering Diseases

HCPCS/CPT codes, reason/remark codes, frequency edits, POS/TOB/provider specialties, and so forth. The requirements described in CR9087 reflect the operational changes that are necessary to implement the conversion of the Medicare shared system diagnosis codes specific to the attached Medicare NCD Table.

Please note that there are 10 spreadsheets attached to CR9087. These spreadsheets relate to 13 NCDs, and provide pertinent policy/coding information necessary to implement ICD-10. Further, you should be aware that NCD policies may contain specific covered, non-covered and/or discretionary diagnosis coding. These spreadsheets are designated as such and are based on current NCD policies and their corresponding edits. Nationally covered and non-covered diagnosis code editing is finite and cannot be revised without subsequent discussions with CMS. Discretionary code lists are to be regarded as CMS’ compilation of discretionary codes based on current analysis/interpretation. Local MACs may or may not expand discretionary lists based on their individual local authority within their respective jurisdictions. Nothing contained in CR 9087 should be construed as new policy. Some coding details are as follows:

1.The ICD-10 diagnosis/procedure codes associated with the NCDs attached to CR9087 are not to be implemented until October 1, 2015, or until ICD-10 is implemented.

2.Your MAC will use default Council for Affordable Quality Healthcare (CAQH) Committee on Operating Rules for Information Exchange (CORE) messages, where appropriate:

•Remittance Advice Remark Code (RARC) N386 (This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered), along with Claim Adjustment Reason Code (CARC) 50 (These are noncovered services because this is not deemed a "medical necessity" by the payer), CARC 96 (Non-covered charge(s). At least one Remark Code must be provided [may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT]), and/or CARC 119 (Benefit maximum for this time period or occurrence has been reached).
3.When denying claims associated with the attached NCDs, except where otherwise indicated, your MACs will use:
•Group Code PR (Patient Responsibility) assigning financial responsibility to the beneficiary (if a claim is received with occurrence code 32(Advance Beneficiary Notice), or with occurrence code 32 and a GA modifier (The provider or supplier has provided an Advance Beneficiary Notice (ABN) to the patient), indicating a signed ABN is on file).
• Group Code CO (Contractual Obligation) assigning financial liability to the provider (if a claim is received with a GZ modifier (The provider or supplier expects a medical necessity denial; however, did not provide an Advance Beneficiary Notice (ABN) to the patient), indicating no signed ABN is on file).



NOTE: For modifier GZ, use CARC 50 and MSN 8.81 (If the provider/supplier should have known that Medicare would not pay for the denied items or services and did not tell you in writing before providing them that Medicare probably would deny payment, you may be entitled to a refund of any amounts you paid. However, if the provider/supplier requests a review of this claim within 30 days, a refund is not required until we complete our review. If you paid for this service and do not hear anything about a refund within the next 30 days, contact your provider/supplier).

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