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Lymphland International Lymphedema Online
| The official medicare website is located at : http://www.medicare.gov/ How to find a prescription plan under medicare: http://www.medicare.gov/MPDPF/Public/Include/DataSection/Questions/MPDPFIntro.asp?version=default&browser=IE%7C6% 7CWinXP&language=English&defaultstatus=0&pagelist=Home&ViewType=Public&PDPYear=2006&MAPDYear=2006&MPDPF%5FMPPF% 5FIntegrate=N From the looks of it there are 2 types of plans you can join: Plans include HMOs, PPOs, and Private-Fee-for-Service plans. They offer complete Medicare- covered health care, including drug coverage, through a single plan. Most of these plans generally offer extra benefits and lower copayments than the Original Medicare Plan. However, you may have to see doctors that belong to the plan or go to certain hospitals to get services. FROM NORD again: Knowing Your Health History Could Save Your Life Most Americans believe that knowing their family health history can be beneficial, but only about one-third have actually tried to gather and record information about family health, according to a recent study by the U.S. Centers for Disease Control and Prevention (CDC). Furthermore, the discussion of family history between physician and patient typically lasts just a few minutes. "But knowing your family history can save your life," US Surgeon General Richard H. Carmona said at a press conference in November to launch a project known as the Family History Initiative. As part of this project, the Department of Health and Human Services has created a new computerized tool, called "My Family Health Portrait," that can be downloaded at www.hhs. gov/familyhistory/ to help in the process. Francis S. Collins, MD, PhD, director of the National Human Genome Research Institute, noted that all people have genetic abnormalities that make them more susceptible to certain illnesses. Tracking illnesses from one generation of a family to the next can help identify illnesses for which the family is at risk. This may allow family members, working with their physicians, to take steps to reduce their risk. The tool guides users through a series of screens to record information for each family member about six common diseases. Other conditions may also be added. After the information has been collected, a diagram can be printed and shared with a physician. All personal information is maintained on the user's computer. No information is given to the government. Eventually, the tool will be available in both English and Spanish. Also, a print version will be provided to those who call the Federal Citizen Information Center at (888) 878- 3256. The federal employees who have worked on this project, from the National Institutes of Health, Surgeon General's office and CDC, hope families will take advantage of being together over the holidays to compile a health history. "It is our hope as families gather this holiday season, they'll take the time to learn-and record-their families' health histories so that they can continue to have years of family gatherings together," said Muin Khoury, MD, director of CDC's Office of Genomics and Disease Prevention. MEDICAID ALERT: Medicare/Medicaid Information regarding insurance with medicare: You automatically qualify for extra help and don't need to apply if you: have Medicare and full coverage from a state Medicaid program that currently pays for your prescriptions. You should join a plan that meets your needs by December 31, 2005 because Medicaid will no longer pay for prescription drugs. If you don't, Medicare will enroll you in a plan effective January 1, 2006 so you don't miss a day of coverage. You can drop the plan or switch to another any time. get help from your state Medicaid program paying your Medicare premiums (belong to a Medicare Savings Program). You should join a plan that meets your needs by December 31, 2005. If you haven't signed up by May 15, 2006, Medicare will enroll you in a plan effective June 1, 2006 so you don't have to pay a penalty. You can drop the plan or switch to another any time. get Supplemental Security Income. You should join a plan that meets your needs by December 31, 2005. If you haven't signed up by May 15, 2006, Medicare will enroll you in a plan effective June 1, 2006 so you don't have to pay a penalty. If Medicare enrolled you in a prescription drug plan, you can switch to another plan one time before December 31, 2006. --------------------- What To Do When Medicare Says 'No' http://www.elderlawanswers.com/resources/article.asp?id=2334&Section=4&state= Your doctor suggested you have a minor operation or procedure, you went ahead and had it done, and now Medicare won't pay for it. What should you do? Appeal. Your provider tells you that your lymphedema compression garments are not covered. What should you do? Appeal. [Added by Bob Weiss] Medicare covers procedures that are deemed medically necessary. "Appealing is easy and most people win so it is worth your while to challenge a Medicare denial," says the Medicare Rights Center, a national nonprofit organization. The denial of coverage may be due, for example, to a simple coding error in your doctor's office. People have a strong chance of winning their Medicare appeal. According to Center, 80 percent of Medicare Part A appeals and 92 percent of Part B appeals turn out in favor of the person appealing. The Medicare Rights Center offers the following tips to maximize your success when appealing your denial: a.. Write "Please Review" on the bottom of your Medicare Summary Notice (MSN), sign the back and send the original to the address listed on your MSN by certified mail or with delivery confirmation. b.. Include a letter explaining why the claim should be covered. c.. When possible, get a letter of support from your doctor or other health care provider explaining why the service was "medically necessary." d.. Save photocopies and records of all communications, whether written or oral, with Medicare concerning your denial. e.. Keep in mind that you only have up to 120 days from the date on the MSN to submit an appeal. The Center notes that the appeals process is slightly different if you are in a private Medicare plan, like an HMO or a PPO. One difference is that you have only 60 days from the date on the denial notice to file an appeal. Resources: For information on how to fight a hospital discharge, click here. For more on the Medicare Rights Center, visit its Web site at http://www.medicarerights.org To download Medicare appeal forms from the government's Medicare website, click here. -------------------------------------------------------------------------------------------- FILING A CLAIM FOR REIMBURSEMENT FOR COMPRESSION GARMENTS * Garment supplier fills out an ABN and gives Beneficiary a copy. Beneficiary pays garment fitter and gets a receipt. Make sure that this is the latest version of Form CMS-R-131. I have the version dated (03/08). This is important since the Section (G) Options were in reverse order from earlier versions. The option to be chosen is the only one which states in bold "I can appeal to Medicare". * If the Supplier should choose to file the claim for the beneficiary, they will file on a Form 1500. Ask that they fill out Item 27 Acceptance of Assignment with a "NO", and further place the note "Beneficiary refuses to assign benefits" in Item 19. (see note below why Supplier may not be motivated to file for the beneficiary). * Beneficiary submits CMS form 1490 Patient's Request for Medical Payment to Medicare requesting reimbursement for the garment listed on the ABN, and attaches receipt. Block 6 Authorization says "... and request payment of medical insurance benefits to me." just above beneficiary's signature. * Medicare sends a denial directly to the Beneficiary. Denial appears on the quarterly Medicare Summary Notice (MSN). After the headers on this form, the sentence "This is a summary of claims processed from ... to ...". Following this there should be a section labeled "Part B Medical Insurance-Unassigned Claims". In the last column "See Notes Section" there will be a series of code letters denoting the reason for the denial. There will also be detailed instructions for appealing the decision. There is a 120-day appeal period after which no appeal will be allowed. * Beneficiary consults Bob Weiss [LymphActivist@aol.com] to proceed further, i.e., several more denials will come down the pike before it goes to an administrative law judge... At this point I will need a copy of the MSN and I will either guide the beneficiary in the first appeal, or I will file it on behalf of the beneficiary. This first appeal to an "independent" Medicare Contractor is called a "Redetermination", the next appeal to a "Medicare Quality Independent Contractor" or a "DME MAC" is a "Reconsideration", and the next appeal is to an Administrative Law Judge (ALJ). None of these appeals costs any more than the cost of making copies and postage. There is a 60-80% chance of a favorable determination by the ALJ. In the event that the ALJ renders an unfavorable decision then we will appeal to the Medicare Appeals Council, where I run about a 50% favorable rate. IF the Beneficiary gets reimbursed after 2 years or so, the ABN states that "If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles." This puzzles me. Does this mean that Medicare will reimburse the garment fitter directly? (That's crazy because it is definintely not in a garment fitter's interest to go to the trouble of submitting an ABN for a Beneficiary only to have to refund their money at a later time). You are correct that the Supplier has little incentive to file your complaint. The supplier receives a reduced amount of reimbursement from the retail price of the item, and if they are a Medicare Supplier they are required to file a claim for something they know will be denied. So they will ask for payment in advance. So as long as they are filing on behalf of the beneficiary it is important for the beneficiary to refuse to assign benefits on the Form 1500. That way there will be no refunds necessary. (Thanks to therapist Kevern Hartmann for providing the framework for this piece and forcing me to research the appeal process. I would ask any reader who discovers any errors or changes to the process to contact me immediately. Please remember that I am not allowed to provide medical or legal advice. All I can do is to read the appropriate regulations and policies and tell you what my understanding is.) Robert Weiss, M.S. Lymphedema Patient Advocate LymphActivist@aol.com -------------------------------------------------------------------------------------------- Abstracted this from an article in the San Francisco Chronicle. This applies to denials of compression bandages, garments and devices, which are medically required in the treatment of lymphedema. Bob Weiss Medical care's state of denial Victoria Colliver, Chronicle Staff Writer Monday, June 23, 2008 http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2008/06/22/MNUK11C28G.DTL&tsp=1 What to do if you are denied medical care If your health insurance carrier is refusing to approve treatment recommended by your doctor, you have a number of options. First, contact your health plan. You probably will have to go through the plan's internal grievance process first. If time is of the essence, ask for an expedited review through the state. Tips to help you get the care you need: -- Review your health plan policy. Many are available online. -- Make sure your doctor is aware of your problem. Sometimes the initial denial comes from the medical group, which is charged with managing costs. In any case, your doctor's support is important. -- Request the reason for the denial in writing. Take detailed notes of all conversations, including the date and time of the call and the name of the person you speak with. Save copies of all paperwork, and keep these records in chronological order. -- Act soon. If you wait longer than six months, you could lose the right to file a complaint, ask for an independent medical review (also called an IMR), or take other action against your health plan such as arbitration or a lawsuit. An IMR decision is binding on the health plan, but not the patient. ------------------------------------------------------------------------------------------- NHIC Provider Education, Medicare Part B Expiration of Therapy Cap Exceptions The exceptions to outpatient therapy caps expire on June 30, 2008. Outpatient therapy service providers should not submit claims with the KX modifier for services furnished on or after July 1, 2008. To the extent possible, CMS is working with Congress, health care providers, and the beneficiary community to avoid disruption in the delivery of health care services and payment of outpatient physical therapy, occupational therapy and speech-language pathology claims for services furnished by physicians, non- physician practitioners, and therapists paid under the physician fee schedule, beginning July 1. For physical therapy and speech language pathology services combined, the limit on incurred expenses is $1810. For occupational therapy services, the limit is $1810. Deductible and coinsurance amounts applied to therapy services count toward the amount accrued before a cap is reached. Therapy cap accruals began on January 1, 2008, and some patients may have reached the annual limits by June 30, 2008. Providers may access the accrued amount or remaining amount of therapy services from the Medicare beneficiary eligibility inquiry and response transactions. Specifically: o For CWF users, the system returns the “appliedâ€� amount. See CR4115 at http://www.cms. hhs. gov/transmit tals/downloads/ /R759CP.pdf o For users of the HETS 270/271, the system returns the “remainingâ€� amount. See the page 18 of the 270/271 user guide at http://www.cms. hhs.gov/HETSHelp /Downloads/ HETS%20270- 271% 20User%20Compan ion%20Guide. pdf o The Medicare contractors' Interactive Voice Response units (IVR) return either the remaining or applied amounts based upon contractor programming. For those few contractors that do not provide this information on their IVRs, providers can call the contractors' customer service representatives. For additional information, Providers and Suppliers should also read the Medicare Claims Processing Manual, chapter 5, section 10. 2 at http://www.cms. hhs.gov/manuals/ downloads/ clm104c05TXT. pdf Patients Who Have Reached Their Limit(s) on Outpatient Therapy Services: Note that patients who have reached their limit(s) on outpatient therapy services, other than those who reside in a Medicare-certified part of a skilled nursing facility, may obtain medically necessary therapy services that exceed the caps if the services are furnished and billed by the outpatient department of a hospital. In other settings, outpatient therapy services in excess of the caps are not covered, and the therapy provider may charge for those services. An Advance Beneficiary Notice is recommended, but not required for services that exceed therapy caps. An ABN is available at the following link: http://www.cms. hhs.gov/BNI/ 02_ABNGABNL. asp#TopOfPage (click on ABN-CMS-R-131 Form). In the box titled "Reason Medicare will not pay" the following language is suggested Medicare will not pay more than $1810 for expenses incurred for physical therapy and speech-language pathology services combined or for occupational services in 2008. Patients may be referred to this website for further information: http://www.medicare .gov/Publication s/Pubs/pdf/ 10988.pdf which will be activated by July 3, 2008. We will continue to be in communication with you with further information about payment of Medicare physician fee schedule claims. In addition, be on the alert for more information about other legislative provisions which may affect you. Reference: JSM/TDL-08387; 7/3/2008 ---------------------------------------------------------------------------------- Extension of Therapy Cap Exceptions July 16, 2008 The Medicare Improvements for Patients and Providers Act of 2008 was enacted on July 15, 2008. One provision of this legislation extends the effective date of the exceptions process to the therapy caps to December 31, 2009. Outpatient therapy service providers may now resume submitting claims with the KX modifier for therapy services that exceed the cap furnished on or after July 1, 2008. For physical therapy and speech language pathology services combined, the limit on incurred expenses is $1810 for calendar year 2008. For occupational therapy services, the limit is $1810. Deductible and coinsurance amounts applied to therapy services count toward the amount accrued before a cap is reached. Services that meet the exceptions criteria and report the KX modifier will be paid beyond this limit. Before this legislation was enacted, outpatient therapy service providers were previously instructed to not submit the KX modifier on claims for services furnished on or after July 1, 2008. The extension of the therapy cap exceptions is retroactive to July 1, 2008. As a result, providers may have already submitted some claims without the KX modifier that would qualify for an exception. Providers submitting these claims using the 837 institutional electronic claim format or the UB-04 paper claim format would have had these claims rejected for exceeding the cap. These providers should resubmit these claims appending the KX modifier so they may now be processed and paid. Providers submitting these claims using the 837 professional electronic claim format or the CMS-1500 paper claim format would have had these claims denied for exceeding the cap. These providers should request to have their claims adjusted in order to have the contractor pay the claim. In all cases, if the beneficiary was notified of their liability and the beneficiary made payment for services that now qualify for exceptions, any such payments should be refunded to the beneficiary. --------------------------------------------------------------------------------------- Seven Mistakes to Avoid When Seeking Social Security Disability BenefitsAllsup outlines missteps that can be obstacles when applying for SSDI benefits.Belleville, Ill. (Vocus) July 11, 2008 -- People with severe disabilities know what it means to wait. They wait medical test results; they wait doctors’ diagnoses and they wait for answers to their questions about the future. Delays are typical for people filing for Social Security Disability Insurance (http://allsup.com/About-SSDI/Free-SSDI-Evaluation.aspx) (SSDI) benefits, but there are ways to avoid common mistakes that make the process even more difficult to navigate, according to Allsup (http://allsup.com/Home.aspx). Founded in 1984 and headquartered near St. Louis, Allsup represents people nationwide for their entitled SSDI benefits.Two-thirds of all SSDI applicants will have their initial claim denied. If they appeal, and even if they are successful, they will go through several additional steps and may wait two years or longer before they ev er see a disability payment. There are some missteps, however, that can actually add time and increase the delay for an SSDI award, according to Allsup.Social Security disability payments are a significant, and often the sole, income source for millions of individuals with disabilities and their families,said Edward Swierczek (http://www.allsup.com/About- Us/News-Room/Resources-for-Journalists/Allsup-Experts/Edward-Swierczek.aspx), senior claimant representative with Allsup. Unfortunately, people with disabilities often make mistakes in applying for their SSDI benefits. This may result in even more delays, which puts more stress on what could already be a precarious financial situation.To help educate claimants, Allsup provides the following information on seven common mistakes people make when filing for SSDI benefits.Seven Common Mistakes When Filing for SSDI1. Going into the process uneducated. Some people believe i's just a matter of filling out a few forms, sending them in and waiting for their checks. They would be surprised to find out just how complicated the SSDI process really is. The Social Security Administration follows a five-step sequential evaluation process to determine if an individual qualifies for disability benefits (http://allsup.com/About-SSDI/Why-You-Want- SSDI.aspx), explained Swierczek, including:* You must not be gainfully employed, which is defined as earning $940 a month or more, * Your condition is severe, meaning it interferes with basic activities of work, * Your condition is on the Social Security Administration's list of disabling conditions, or medically equals one of the disabling conditions on the list, and you will be disabled for more than 12 months, * You are not able to do the work you had been doing before the impairment, and, * You can't perform any other type of work. You have to meet the first two criteria before the Social Security Administration will consider your claim, said Swierczek, who has more than 30 years of experience helping individuals through the complexities of the SSDI application process (http://allsup.com/About-SSDI/SSDI-Process.aspx). If you're a 40-year-old ironworker who hurt your back, the Social Security Administration may find that you are not disabled if you can do desk work. You may not think you can, but if you don't provide compelling evidence20why you can't, they will deny your claim, he said.2. Going through the SSDI process alone. Individuals who apply for Social Security Disability Insurance benefits (http://www.allsup.com/About- SSDI/Choosing-Representation.aspx) without representation are more likely to have their claim denied. Working with government agencies and understanding the nuances of what's needed to comply with the regulation isn't something the average person is aware of, said Allsup senior claimant representative David Bueltemann (http://www.allsup.com/About-Us/News-Room/Resources-for-Journalists/Allsup- Experts/David-Bueltemann.aspx), who has successfully represented thousands of SSDI applicants.“Just as people hire accountants to complete their tax returns and represent them before the Internal Revenue Service if the're audited, individuals are recognizing they need representation when they go into the Social Security Disability Insurance process, he added.3. Underestimating the impact of your disability. Sometimes pride leads people to underplay the extent of their disabilities because they have endured a condition so long that they have learned how to cope with the stress of daily life. But many people underestima te how much their disability affects their day-to-day lives. A good example, Bueltemann explained, is a 50-year-old grandmother who tells the state Disability Determination Service (DDS) that she takes care of her grandchildren. If the woman doesn't explain that the children are teen-agers and self-sufficient, the DDS may deny her claim because it believes that she is capable of working in a day care center.4. Exaggerating the impact of your disability. On the other end of the spectrum are people who want to make their condition appear worse than it is. For example, a man who uses a cane at a hearing before an administrative law judge but does't normally use a cane would be over-representing his condition. “If the judge asks to look at the cane and sees the tip is not worn, the claim is immediately suspect, even though the claimant may have had a legitimate case if he’d just stuck to the unexaggerated truth, Swierczek explained. It is important to elaborate, but not exaggerate.â€�5. Being vague about your work history. Knowing what the expectations are for your work, and showing accurately from the outset why you can't perform this work any longer, is an essential part of qualifying for SSDI benefits (http://www.allsup.com/About-SSDI/SSDI-Guidelines-by- Disability.aspx). For example , Swierczek said, a service technician might be required to drive for extended periods as part of the job.If your impairment means you can only drive for 10 minutes without experiencing extreme pain, yet your job requires you drive in 60-minute stretches, you need to make it clear on your disability application what the work expectations are and what your limitations are, said Swierczek. Otherwise, you may end up in double jeopardy: Your disability claim is rejected because the Social Security Administration believes you can still perform your work, he said. But you're out of work because you really can't meet the requirements of the job.. Missing the appeals deadline. The Social Security Administration denies more than 60 percent of all initial SSDI applications, but there is a formal appeals process with three levels. If you are rejected at any level, you have only 60 days to appeal to the next level. If you miss the deadline, you need to start the process from the beginning. If you've applied on your own and received a denial, it's not too late to choose an SSDI representative (http://www.allsup.com/Allsup- Representation/How-It-Works-At-Allsup.aspx), such as Allsup, to handle the appeal and continue with your case. Taking this step may make the differenc e in experiencing further delays to receiving your SSDI benefits.7. Giving up. The process can be excruciatingly long and cumbersome. Nearly 750,000 people are waiting for a hearing before an administrative law judge, which is only one level of the SSDI appeals process. For individuals already facing significant physical or mental disabilities, this delay can add to the difficulty. Bueltemann, however, is quick to point out that receiving SSDI is a benefit that individuals with disabilities and their families have earned, if they meet the SSDI requirements. An SSDI award also is essential in securing other forms of financial support, including Medicare benefits (http://www.allsup. com/Financial-Matters/Managing-Healthcare-Costs/Medicare.aspx) and retirement protection.It may not be as easy as it should be to receive your payments, but do not give up, Bueltemann said.Make sure you have good representation and don't lose hope that you can secure your benefits.ABOUT ALLSUPAllsup, Belleville, Ill., is a leading nationwide provider of financial and healthcare related services to people with disabilities. Founded in 1984, Allsup has helped more than 100,000 people receive their entitled Social Security Disability Insurance and Medicare benefits. Allsup employs more than 500 professionals who deliver services directly to consumers and their families, or through their employers and long-term disability insurance carriers. For more information, visit www.Allsup.com.Contacts: Allsup - Rebecca Ray(800) 854- 1418, ext. 5065 Dan Allsup, ext. 5760. ---------------------------------------------------------------------------------------- I have no idea if this is good or not, cause if the cap is 1810, my therapy for less than 2 weeks 3 years ago was almost $9,000 so what good is 1810? Well I hope this does help someone out there and that it is a good thing. If you are on Medicare and are provided lymphedema treatment by a Medicare-approved physical therapist, you do not pay (except for deductables and 20% co-pay) for the service up to $1800. The therapist is not alowed to charge any more, and (s)he is reimbursed by Medicare. The reimbursement rates vary from state to state, but run about $25 per unit, with 3-4 units per visit, that provides about 15-20 visits. But this annual limit has been suspended for many years by Congress, but is now back in place. But Congress has also said that in cases where there is a medical necessity for more than the capped amount per year, there would be an exception process for certain conditions. Last year lymphedema was on the list of exception conditions, so the limit did not apply. But starting July 1, the exception process expired. This new law just put the exception process back. That's good, since if you need more than 15-20 treatments in any one year for your lymphedema, you can have them justified. I have no idea how your therapist charged you $9,000 for a course of lymphedema treatment. Did that cost include bandages or garments (not covered by Medicare)? Bob Weiss Lymphedema Patient Advocate ----------------------------------------------------------------------------------- Bob... I just got a new prescription for Compression hose... I have never worn any... I just can't afford them right now.. I had one RX but did not even try to get them because I knew that I could not afford them.. I am on Medicaid.. should I try with this RX and then when I get turned down then try the appeals process or should I wait until I can afford a pair and then try and after I have to pay for them go for an appeal? I really just can't afford them.. I can't afford my treatment at all.. so I am just waiting in limbo right now... It is a little hard to do when I get fluid in my knees and can't stand up on my own at times... any advice???? Thanks, Marbeth :) Marbeth, Find a Medicare approved supplier and give them a copy (you keep the original) of the doctor's prescrition and ask them to request an advanced approval to Medicaid and to Medicare if you are on both. It will be denied, but you will then have something to appeal and a claim number that can be tracked. The prescription should clearly state that the stocking is necessary to treat your lymphedema, with the appropriate diagnostic code. Bob Weiss ---------------------------------------------------------------------------------- By accepting the denial of treatment or a compression garment on the basis of the the letter of denial which says it is not covered, we allow this insurance travesty to continue. Appeal each and every denial of lymphedema treatment. If you run into what appears to be a brick wall contact me and I'll see how to approach an appeal. Bob Weiss Lymphedema Treament Advocate ================================================================= San Francisco Chronicle Examines Health Insurance Claim Denials The San Francisco Chronicle on Monday examined how "[e]ach year, thousands of Californians find themselves at odds with their health insurers over whether they, as patients, should get the treatment their doctors prescribed." Insurers say that physicians do not always prescribe the most cost-effective treatments. Anthem Blue Cross says it follows strict protocols in denying care and relies on medical evidence to determine what care is appropriate. Michael Belman, Anthem's medical director, said, "Even in a dire situation, it is ethically appropriate to withhold treatment if it's not effective." Alan Sokolow, chief medical officer for Blue Shield of California, said, "We think that is our job -- to help patients and providers apply the benefit package the patient has, the dollars they put for insurance coverage and health care, in the most appropriate and effective way," adding that patients should appeal denials if they disagree. According to the Chronicle, in 2007, the state's HMO Help Center received about 90,000 calls from individuals with health insurance disputes. The majority of disputes involved whether treatment or procedures prescribed by physicians were "medically necessary" or considered "experimental" or "investigational." The state Department of Insurance, which regulates a smaller number of insurance plans, received 35,280 complaints and resolved 262 independent medical review cases in 2007. The Department of Managed Health Care since 2001 has offered third-party medical reviews and has resolved 1,716 IMRs since 2007. According to DMHC, roughly 40% of decisions are settled in favor of the patient. Jerry Flanagan, health advocate for Consumer Watchdog, said that issues arise because health insurers "are going back to the old strategies of the '90s, when they interrupted care on the front end by denying or delaying treatment offered by a doctor." He said insurers hope patients will not dispute the decisions or settle for less, in order to save money -- a statement that insurers dispute. The Chronicle also profiled the cases of three individuals whose claims were denied by insurers (Colliver, San Francisco Chronicle, 6/23). ------------------------------------------------------------------------------ see link to upcoming CMS public meeting agenda regarding Durable Med http://www.cms. hhs.gov/MedHCPCS GenInfo/Download s/HCPCS_Meeting_ Agenda_DME_ 052808. SEE page 11 -- topic 08.71 Garments to be discussed : FLEXITOUCH. We need to continue to contact our local politicians to continue to push for all lymphedema garments expenses to be covered! Thanks Lisa for the heads-up. This request is for Medicare Codes for the body garments used with the Flexitouch pneumatic compression controller. They are coded as "durable medical equipment" since they are used in conjunction with a piece of durable medical equipment. This ruling will in no way affect coverage of compression bandages or garments, which are a different Medicare benefit category (i.e. "prosthetic devices"). I'm afraid that while contacting our local politicians serves a valuable educational function, it will not achieve coverage without either a new law or by forcing CMS to re-interpret the current law. And to do the latter, there must be a ground-swell of appeals from lymphedema patients who are denied coverage for their garments. I will make this offer: If you file a claim for the garments or bandaging kits that you paid for in the last couple of months, when the denial comes from your insurance company or from Medicare, I will help you file the three appeals necessary to reach an Administrative Law Judge. At this point you have a good chance of being reimbursed. I do not charge for this help. I'm trying to get favorable decisions from as many different ALJs as I can. Then I will confront CMS for a change in their interpretation of the Social Security Act. I will also help your Congressional representative draft and introduce a bill to change Medicare, if you can interest him or her in your cause. Robert Weiss, M.S. Lymphedema Treatment Advocate National Lymphedema Network ------------------------------------------------------------------- There have been recent "clarifications" to the "incident to" physician services rules which may impact provision of therapy services for some lymphedema therapists. The changes to the policies are summarized in http://www.cms. hhs.gov/MLNMatte rsArticles/ downloads/ MM5288.pdf with the full-text policy revisions given in http://www.cms. hhs.gov/Transmit tals/downloads/ R87BP.pdf ------------------------------------------------------------------------------------------- Settlement to Ease Drug Costs for Some on Medicare By ROBERT PEAR http://www.nytimes.com/2008/06/20/health/policy/20drug.html?_r=1&ref=health&oref=slogin Published: June 20, 2008 WASHINGTON - The Bush administration promised on Thursday to provide new protections for low-income Medicare beneficiaries to ensure they can get prescription drugs promptly, at minimal cost. The promise came in the proposed settlement of a nationwide class-action lawsuit filed on behalf of hundreds of thousands of people who have had difficulty getting the medicines they need. Under the 2003 Medicare law, more than six million people eligible for both Medicare and Medicaid are entitled to extra help with their drug costs. But in many cases, they could not get the assistance, so they did not receive the drugs they needed, or they experienced long delays. In early 2006, low-income beneficiaries were often overcharged, and some were turned away from pharmacies without getting their medications. Several states declared public health emergencies, and many stepped in to pay for prescriptions that should have been covered by the federal Medicare program. Under the proposed settlement, filed Thursday with the United States District Court in San Francisco, federal Medicare officials promised to speed up the process of providing extra help to low-income people, who now could qualify within days, rather than weeks or months. Drug benefits are delivered by private insurers under contract to Medicare. Under the settlement, these insurers will have to provide medications at minimal cost for any Medicare recipients who prove they have low incomes and qualify for extra help. For most people with incomes less than the poverty level ($10,400 a year for an individual), the maximum co-payment is $1.05 for a generic or preferred brand-name drug and $3.10 for other prescription drugs. But many beneficiaries have been asked to pay much higher amounts, from $30 to $75 or more, because the evidence of their low-income status was not properly shared among federal and state agencies, insurance companies and pharmacies. "This settlement agreement is a victory for many of the nation's most vulnerable citizens, who have faced life-threatening delays in obtaining vital medications," said Kevin Prindiville, a lawyer at the National Senior Citizens Law Center, which filed the lawsuit with another nonprofit group, the Center for Medicare Advocacy. Gill Deford, a lawyer at the Center for Medicare Advocacy, said the settlement would "help hundreds of thousands of people a year get their prescription drugs more quickly, at nominal cost." Jeff Nelligan, a spokesman for the federal Centers for Medicare and Medicaid Services, said federal officials had "worked tirelessly" to ensure that Medicare recipients could fill their prescriptions. He refused to comment on the substance of the settlement, noting that it was subject to approval by Judge Thelton E. Henderson of Federal District Court in California. States administer the Medicaid program. They have crucial information showing whether Medicare beneficiaries are also enrolled in Medicaid and therefore eligible for extra help with their drug costs. Under the settlement, if a beneficiary claims to be eligible for the low-income subsidy but does not have the documents to prove it, and if the person is about to run out of a medication, federal officials would immediately contact the state Medicaid agency to check whether the person had been on Medicaid. -------------------------------------------------------------------------------- News from New York State Assemblyman ALAN N. MAISEL 59th ASSEMBLY DISTRICT Date: June 23, 2008 Assembly Passes Maisel Measure To Raise Awareness of Lymphedema Today, in Albany, Assemblyman Alan Maisel (D-Kings County) announced passage in the Assembly of legislation to promote lymphedema and lymphatic disease reporting and awareness (A05892B). TThe measure requires health care providers, who are already required to report cases of cancer or oother malignant disease, to also report instances of lymphedema related to cancer treatment in their patients. This legislation also requires the Department of Health to develop a health care and wellness education and outreach program for those seeking information on either primary or secondary lymphedema. "Lymphedema is not a high profile disease like cancer or diabetes that generates a lot of press or mmoney for research, yet it affects an estimated six million men, women and children in the United States," stated Maisel. "The lymphatic system is vital to the health of every individual as it is an integral part of tthe immune system.â€� Lymphedema is an accumulation of lymphatic fluid that causes painful, disfiguring sswelling, usually in the arms or legs. There are two major types of lymphedema: primary (congenital) and ssecondary (caused by tissue injury, scarring, lymph node removal, or infection). "The largest group of people who acquire secondary lymphedema arc cancer patients, including those with breast, prostate, lung, and melanoma patients," stated Maisel. "This bill helps to ensure that when lymphedema is acquired from the life-saving cancer treatments, these instances of disease are also rreported to the cancer registry. This will help raise awareness of the disease and hopefully increase the mmoney raised to fund additional research to help find the cause of and cure for lymphatic diseases, lymphedema, and related disorders." "It amazes me that despite the essential role the lymphatic system plays in human health, awareness, education and research have been relatively neglected," stated Maisel. "This lack of focus has created barriers to effective delivery of health care and public education about these diseases, its diagnosis, treatment, therapy and long-term care. This legislation, which is on third reading in the Senate, is just the first step in raising public awareness about lymphedema." -------------------------------------------------------------------------------------------- UNINSURED STATS: At its best, the United States health care system is second to none. It is quick to adopt and diffuse new technologies.1 It scores best in the world for patient participation in treatment decisions, respect for confidentiality, provision of prompt care, respect for patients, and clean surroundings.2 But despite having the highest health care spending per capita, the U.S. consistently scores at or near the bottom in comparisons with other developed, high income countries on infant mortality, life expectancy, and the proportion of the population with health insurance coverage (OECD, 2002, WHO, 2000). Almost everyone in these countries has coverage. In the U.S., by contrast, 15.3 percent of the population - or 44.8 million people – were uninsured in 2005.3 What are the consequences of 36.7 million adults and 8.1 million children living without health insurance coverage? In a sweeping 6-volume series on the consequences of uninsurance, the Institute of Medicine reported the following conclusions: Compared to people with insurance, uninsured children and adults experience worse health and die sooner. Families can suffer emotionally and financially when even a single member is uninsured. "Uninsurance at the community level is associated with financial instability for health care providers and institutions, reduced hospital services and capacity, and significant cuts in public health programs, which may diminish access to certain types of care for all residents, even those who have coverage."4 The nation as a whole is economically disadvantaged as a result of the poorer health and premature death of uninsured Americans. The IOM estimated that the lost economic value of uninsurance is between $65 billion and $130 billion annually.5 -------------------------------------------------------------------------------- Sources 1Docteur, Elizabeth, Hannes Suppanz, and Jaejoon Woo. 2003. The US Health System: An Assessment and Prospective Directions for Reform. Economics Department Working papers No. 350. Accessed May 28, 2004. Available at www.oedc.org/eco. 2Findings based on surveys conducted in 35 countries. World Health Organization. 2000. The World Health Report 2000—Health Systems: Improving Performance. Geneva, Switerland. 3Employee Benefit Research Institute estimates from the March Current Population Survey, 2006 Supplement. 4Institute of Medicine. 2004. Insuring America's Health. Washington, DC: National Academy Press, p. xi 5Institute of Medicine. 2004. Insuring America’s Health. Washington, DC: National Academy Press, p. xi. Coverage Matters for Individuals Public opinion on this question has shifted overtime; but in 1993, when health care was at the top of the national political agenda, fully 43 percent of Americans agreed with the statement that uninsured people are "able to get the care they need from doctors and hospitals."1 And just 7 years ago, in 1999, a majority (57 percent) of Americans held this view. Clearly, there is a commonly held belief in this country that uninsured Americans get the health care they need.2 However, available evidence shows that this belief is clearly false. Adults In their landmark study of the consequences of uninsurance,3 the Institute of Medicine concluded that "adults without coverage do not get the care they need and are more likely to suffer poor health and premature death than are insured adults." A more recent study also found that the uninsured receive less care than the insured and experience poorer outcomes.4 Long-term studies indicate that, compared to insured adults, uninsured adults have a 25 percent greater risk of premature death. This mortality difference exists after social, demographic, health status and health behavior differences are statistically removed.5 The Institute of Medicine estimates that the number of excess deaths each year among uninsured adults, age 25-64, is 18,000.6 By way of comparison, consider the number of estimated annual deaths in the under age 65 population due to the following causes: - Diabetes: 17,500 - Stroke: 19,000 - HIV/AIDS: 14,100 - Homicide 19,7007 Preventive Care Uninsured adults are less likely to receive recommended preventive and screening services than insured adults. This includes: - Pap tests for cervical cancer in women, - Clinical breast exams and mammography in women, - Fecal occult blood tests for colorectal cancer, - Sigmoidoscopies for colorectal cancer, - Blood pressure checks for hypertension, and - Cholesterol tests.8 Compared to adults with insurance, when uninsured adults receive screening services, they are less likely to receive them on a timely basis.9 Because they lack timely access to screening services, uninsured adults with cancer (breast, colon, prostate) tend to have poorer outcomes and are more likely to die prematurely than adult cancer patients with insurance. Poor access to screening services results in delayed diagnosis; and survival probability is a function of the stage of the cancer at diagnosis.10 The longer adults under age 65 are without health insurance, the less likely they are to receive preventive services.11 Health insurance coverage increases access to and use of preventive services, but it does not erase disparities in the use of these services among racial groups.12 Chronic Care Chronic conditions—including cardiovascular disease, diabetes, terminal kidney disease, HIV infection, and mental illness—are the leading cause of death, disability, and illness in the United States.13 Uninsured adults with cardiovascular disease receive fewer professionally recommended services and experience worse health outcomes than insured adults with cardiovascular disease. They are less likely to: - be screened for hypertension and high cholesterol,14 - have their blood pressure monitored frequently,15 and - stay on drug therapy for hypertension.16 Diabetes requires intensive care management, but non-elderly adult diabetics are almost as likely to be uninsured as non-elderly adults in general.17 - Compared to insured non-elderly adults with diabetes, uninsured diabetics are less likely to receive appropriate standards of care, which can lead to uncontrolled blood sugar levels, greater risk of hospitalization, and increased risk of additional chronic disease and disability.18 - Among non-elderly adult diabetics, lack of insurance is associated with less glucose monitoring and fewer foot and eye exams. These services are professionally recommended disease management strategies.19 Compared to insured non-elderly adults, those without insurance - who have end-stage renal disease are more likely to begin dialysis once the disease has progressed to a more advanced stage, which has a negative effect on health outcomes.20 - who have HIV infection are less likely to receive the most effective drugs, are more likely to fail to receive needed care21 , and have a higher risk of mortality.22 Compared to insured adults with behavioral health coverage, uninsured adults are less likely to receive mental health services consistent with recommended treatment guidelines.23 Uninsured adults with severe mental illness are much less likely to use specialty mental health services than publicly insured persons. 24 Pregnant Women and Children After conducting an exhaustive review of the literature, the Institute of Medicine concluded that "[h]aving health insurance increases the chances that infants, children, and pregnant women will receive preventive services when well, and timely medical care when sick or at high risk of poor outcomes. These, in turn, help avoid unnecessary hospitalizations, premature births, extended morbidity, or even death."25 The IOM was careful to note, however, that "[a]lthough having insurance makes a difference, simply making insurance available may not be enough to improve health care and health outcomes for all of the uninsured. Some high-risk groups may require additional services (e.g., educational interventions, targeted case management) if they are to obtain good preventive and routine care."26 Pregnant Women Uninsured pregnant women use fewer prenatal services than publicly or privately insured pregnant women. In one study, the rate of unmet needs reported by uninsured women (18 percent) was more than twice that of insured women.27 Pregnant women without health insurance are less likely to receive expensive maternity and neonatal services. For example, the caesarian section rate for uninsured women is lower than the rate for insured women. Although it is believed by some that c-section is an overused procedure, a study that examined insurance status differences in c-section rates when it was an appropriate procedure (in cases of breech presentation or fetal distress) found lower use rates among uninsured women.28 Medicaid expansions during the late 1980s brought public coverage to many previously uninsured women. Although the evidence is mixed, some studies show significant population-level changes in the use of prenatal services following Medicaid expansion.29 Children Uninsured children have less access to health care providers and use health services less frequently than children with private or public insurance.30 When previously uninsured children are enrolled in public insurance programs, they use more health services and use health services more appropriately.31 Multiple factors hinder children's access to, and use of, health services, including low income, immigrant status, and certain race/ethnicity categories. Because 40 percent of children in one of these groups are in at least one other, the barriers to health care access and use are compounded for many children.32 Although having insurance coverage improves access to and use of care for children, other important factors include "poverty, diet, exercise, smoking, and other behavioral factors."33 -------------------------------------------------------------------------------- Sources 1Blendon et al., 1999, p. 207 (IOM, p 21, bottom) 2Institute of Medicine (IOM). 2001. Coverage Matters. Insurance and Health Care. Washington, DC: National Academy Press, p. 21. 3Institute of Medicine (IOM). 2001. Coverage Matters. Insurance and Health Care. Washington, DC: National Academy Press; Institute of Medicine (IOM), 2002. Care Without Coverage. Too Little, Too Late. Washington, DC: National Academy Press; Institute of Medicine (IOM). 2002. Health Insurance is a Family Matter. Washington, DC: National Academy Press; Institute of Medicine (IOM). 2003. A Shared Destiny. Community Effects of Uninsurance. Washington, DC: National Academy Press; Institute of Medicine (IOM). 2003. Hidden Costs, Value Lost. Uninsurance in America. Washington, DC: National Academy Press 4Hadley, Jack, 2007. "Insurance Coverage, Medical Care Use, and Short-term Health Changes Following an Unintentional Injury or the Onset of a Chronic Condition," Journal of the American Medical Association 297:1073-1084.5Franks, Peter; Carolyn Clancy, and Marthe Gold. 1993. Health Insurance and Mortality. Evidence from a National Cohort. Journal of the American Medical Association 27(6):737-741. 5Franks, Peter; Carolyn Clancy, and Marthe Gold. 1993. Health Insurance and Mortality. Evidence from a National Cohort. Journal of the American Medical Association 27(6):737-741. 6Institute of Medicine (IOM), 2002. Care Without Coverage. Too Little, Too Late. Washington, DC: National Academy Press pp. 161-165 and Table D.1. 7Institute of Medicine (IOM). 2004. Insuring America's Health. The National Academies Press, Washington, D.C., p. 46. 8For multiple sources, see Institute of Medicine (IOM), 2002. Care Without Coverage. Too Little, Too Late. Washington, DC: National Academy Press, pp. 47-51. 9Institute of Medicine (IOM), 2002. Care Without Coverage. Too Little, Too Late. Washington, DC: National Academy Press, p. 48. 10Institute of Medicine (IOM), 2002. Care Without Coverage. Too Little, Too Late. Washington, DC: National Academy Press, pp. 52-57. 11Ayanian, John, Joel Weissman, Eric Schneider, Jack Ginsburg, et al. 2000. Unmet Health Needs of Uninsured Adults in the United States. Journal of the American Medical Association 284(16):2061-2069. 12Has, Jennifer and Nancy Adler. 2001. The Causes of Vulnerability: Disentangling the Effects of Race, Socioeconomic Status and Insurance Coverage on Health. Background paper prepared for the Committee on the Consequences of Uninsurance. 13Centers for Disease Control and Prevention (CDC). 2000. "Chronic Disease Prevention: Heart Disease and Health Promotion." Web page, not accessible on April 13, 2004, but see other performance plans at www.cdc.gov/od/perfplan/ 14Ayanian, John, Joel Weissman, Eric Schneider, Jack Ginsburg, et al. 2000. Unmet Health Needs of Uninsured Adults in the United States. Journal of the American Medical Association 284(16):2061-2069. 15Fish-Parcham, Cheryl. 2001. Getting Less Care: The Uninsured with Chronic Health Conditions. Washington, DC: Families USA Foundation. 16Huttin, Christine, John Moeller, and Randall Stafford. 2000. Patterns and Costs for Hypertension Treatment in the United States. Clinical Drug Investigation 20(3):181-195; Fish-Parcham, Cheryl. 2001. Getting Less Care: The Uninsured with Chronic Health Conditions. Washington, DC: Families USA Foundation.2001 17Harris, Maureen. 1999. Racial and Ethnic Differences in Health Insurance Coverage for Adults with Diabetes. Diabetes Care 22(10):1679-1682. 18Palta, Mari, Tamara LeCaire, Kathleen Daniels, Guanghong Shen, et al. 1997. Risk Factors for Hospitalization in a Cohort with Type 1 Diabetes. American Journal of Epidemiology 146(8):627-636. 19Beckles, Gloria, Michael Engelgau, KM Venkat Narayan, William Herman, et al 1998. Population- Based Assessment of the Level of Care Among Adults with Diabetes in the U.S. Diabetes Care 21(9):1432- 1438. 20Obrador, Gregorio, Robin Ruthazer, Arora Pradeep, Annamaria Kausz, et al. 1999. Prevalence of and Factors Associated with Suboptimal Care Before Initiation of Dialysis in the United States. Journal of the American Society of Nephrology 10(8):1793-1800.; Kausz, Annamaria T., Gregorio T. Obrador, Pradeep Arora, Robin Ruthazer, et al. 2000. Late Initiation Dialysis Among Women and Ethnic Minorities in the United States. Journal of the American Society of Nephrology 11(12):2351-2357. 21Cunningham, William E., Ron D. Hays, Kevin W. Williams, Keith C. Beck, et al. 1995. Access to Medical Care and Health-Related Quality of Life for Low-Income Persons with Symptomatic Human Immunodeficiency Virus. Medical Care 33(7):739-754; Cunningham, William E., Ronald M. Andersen, Mitchell H. Katz, Michael D. Stein, et al. 1999. The Impact of Competing Subsistence Needs and Barriers on Access to Medical Care for Persons with Human Immunodeficiency Virus Receiving Care in the United States. Medical Care. 37(12):1270-1281; Katz, Mitchell H., Sophia W. Chang, Susan P. Buchbinder, Nancy A Hessol, et al. 1995. Health Insurance and Use of Medical Services by Men Infected with HIV. Journal of Acquired Immune Deficiency Syndrome and Human Retrovirology. 8(1):59-63; Shapiro, Martin F., Sally C. Morton, Daniel F. McCaffrey, J. Walton Senterfitt, et al. 1999. Variations in the Care of HIV- Infected Adults in the United States. Journal of the American Medical Association 281(24): 2305-2315. 22Goldman, Dana P., Jayanta Bhattcharya, Daniel F. McCaffrey, Naihua Duan, et al. 2001. Effect of Insurance on Mortality in an HIV-Positive Population in Care. Journal of the American Statistical Association 96(455): 833-894. 23Cooper-Patrick, Lisa, Rosa M. Crum, Laura A. Pratt, William W. Eaton, et al. 1999. The Psychiatric Profile of Patients with Chronic Disease Who Do Not Receive Regular Medical Care. International Journal of Psychiatry 29(2): 165-180; Sturm, Roland, and Kenneth B. Wells. 1995. How Can Care for Depression Become More Cost-Effective? Journal of the American Medical Association 273(1): 51-58. 24McAlpine, Donna D., and David Mechanic. 2000. Utilization of Specialty Mental Health Care Among Persons with Severe Mental Illness: The Roles of Demographics, Need, Insurance, and Risk. Health Services Research 35(1): 277-282. 25Institute of Medicine, 2002. Health Insurance is a Family Matter. The National Academies Press, Washington, D.C., pp. 136-7. 26Institute of Medicine, 2002. Health Insurance is a Family Matter. The National Academies Press, Washington, D.C., p. 139. 27Bernstein, Amy. 1999. Insurance Status and Use of Health Services by Pregnant Women. Washington, DC: March of Dimes. 28Stafford, Randall. 1990. Cesarean Section Use and Source of Payment: An Analysis of California Hospital Discharge Abstracts. American Journal of Public Health 80(3):313-315. 29Institute of Medicine (IOM). 2002. Health Insurance is a Family Matter. Washington, DC: National Academy Press, pp.128-130. 30Institute of Medicine (IOM). 2002. Health Insurance is a Family Matter. Washington, DC: National Academy Press, pp. 111ff. 31Currie, Janet and Jonathan Gruber. 1996. Health Insurance Eligibility, Utilization of Medical Care and Child Health. Quarterly Journal of Economics 111(2):431-466; Szilagyi, Peter, Jack Zwanger, Lance Rodewald, Jane Holl, et al. 2000. Evaluation of a State Health Insurance Program for Low-Income Children: Implications for State Child Health Insurance Programs. Pediatrics 105(2): 363-371; Lave, Judy, Christopher Keane, Chyongchiou Lin, Edmund Ricci, et al. 1998. Impact of a Children's Health Insurance Program on Newly Enrolled Children. Journal of the American Medical Association 279(22):1820-1825. 32Newacheck, Paul, Dana Hughes, and Jeffery Stoddard. 1996. Children's Access to Primary Care: Differences by Race, Income, and Insurance. Pediatrics 97(1): 26-32. 33Institute of Medicine (IOM). 2002. Health Insurance is a Family Matter. Washington, DC: National Academy Press, pp.IOM, 2:9 top. Health care spending in the United States has grown rapidly since the 1960s, at an average rate of 10 percent a year. In 2005, nearly $2 trillion was spent on health care in the United States. The amount of money spent on health care is expected to increase to $4.1 trillion by 2016.1 Spending on health care accounted for about 16 percent of Gross Domestic Product (GDP). By 2016, the Center for Medicare and Medicaid Services (CMS) projects that health care will account for about 20 percent of GDP.2 While health care spending has been increasing, the distribution of health care spending among different services has been changing. Since the 1980s, the percentage of health care spending for hospital care has declined. In 1980, hospital care accounted for 40 percent of all health care spending. By 2004, it accounted for 30 percent, and is expected to remain at roughly 31 percent between now and 2016.3 By contrast, the share of spending for physician and other professional services rose over the same time period, from 27 percent of in 1980 to 28 percent in 2005. It is expected to fall slightly to 26 percent through 2016.4 The share of health care spending accounted for by prescription drugs increased from 5 percent in 1980 to 10 percent in 2005, and is expected to reach 12 percent in 2016.5 The cost of providing health care services has been increasing faster than the Gross Domestic Product (GDP) since 1998, but the gap between the two declined recently as the economy recovered from recession and health care costs grew more slowly. During 2001, health care costs increased 11.3 percent, while GDP increased by only 2.1 percent. By 2006, health care costs increased 7.7 percent, compared to 5.9 percent GDP growth.7 Recent spending on health care services has slowed for all categories of health care, but cost increases for hospital outpatient services and prescription drugs continue to outpace those for inpatient and physician services. Sources 1Employee Benefit Research Institute estimates from Centers for Medicare and Medicaid Services and U. S. Department of Commerce. 2Employee Benefit Research Institute estimates from Centers for Medicare and Medicaid Services and U. S. Department of Commerce. 3Employee Benefit Research Institute estimates from Centers for Medicare and Medicaid Services. 4Employee Benefit Research Institute estimates from Centers for Medicare and Medicaid Services. 5Employee Benefit Research Institute estimates from Centers for Medicare and Medicaid Services. 6Employee Benefit Research Institute estimates from Centers for Medicare and Medicaid Services. 7Strunk, Bradley C., Paul B. Ginsburg, and John P. Cookson. "Tracking Health Care Costs: Declining Growth Trend Pauses In 2004." Health Affairs Web Exclusive, June 21, 2005; and Ginsburg, Paul B., Bradley C. Strunk, Michelle I. Banker, and John P. Cookson. "Tracking Health Care Costs: Continued Stability But At High Rates In 2005.." Health Affairs Web Exclusive, Oct. 3, 2006. ================================================================= The Office of the Medicare Beneficiary Ombudsman was set up to help Medicare Beneficiaries with their problems with Medicare. The MBO web page is http://www.cms.hhs.gov/center/ombudsman.asp The following are some important links to resources in and outside this organization: Office of the Medicare Beneficiary Ombudsman • http://www.medicare.gov/Publications/Pubs/pdf/11173.pdf • http://www.cms.hhs.gov/OpenDoorForums/downloads/Ombudsman0506ReporttoCongress.pdf • Contact Us - If you have an issue that requires a response, please contact 1-800-MEDICARE. If your inquiry requires a response from the Medicare Ombudsman, 1-800-MEDICARE will direct your inquiry to the Medicare Ombudsman. Resources for Assistance with Medicare Issues • http://www.medicare.gov/CallCenter.asp- Get general information about MEDICARE. • http://www.medicare.gov/Ombudsman/resources.asp - Provides information regarding how to file an inquiry, complaint, grievance, or appeal across different areas of Medicare. Other Helpful Resources • http://www.medicare.gov/contacts/Static/RelatedWebsites.asp - Allows you to access other websites that can provide additional help or information that is not presented in www.medicare.gov. • http://www.hhs.gov/od/ - The Office of Disability oversees the implementation and coordination of disability programs, policies and special initiatives for persons with disabilities. • http://www.aoa.gov/eldfam/eldfam.asp- The Administration on Aging provides home and community- based services and opportunities to older persons and their caregivers through programs funded under the Older Americans Act. • http://www.cms.hhs.gov/home/medicaid.asp - If you can't pay for your medical expenses right now, this is the place to find information on assistance that may be available. ================================================================= HOW TO GET THE BEST CARE IN MEDICAL FACILITIES This message is off topic, but posted here because it is something that is likely to affect almost everyone at one time or another. This information may be helpful to prevent unnecessary illness or suffering, and may even save a life. The material came from a list that discusses health care insurance issues and policies, and managed care. Most list members are either physicians or lawyers. The owner of the list is both, and is affiliated with UCLA. I posted this information to another list, and several individuals wondered about MRSA, one of the things discussed in the article. To avoid confusion, the material I posted in response to the inquiries is also posted here. The reason for this post is to advise the public, regarding use of advocates to assist patients in hospitals, nursing homes, and other such similar residential medical institutions to obtain proper assistance when someone is in a medical facility, and to prevent injuries and death. It was never meant to constitute medical advice. Information about this (or any other medical) condition, how to diagnose it, treat it, or prevent it should be discussed with medical providers, not this list. This is posted for educational purposes only. It does not constitute medical or legal advice. Any questions regarding this material should be directed to undersigned poster, at X1234567890@Juno.Com subject: HEALTH CARE FACILITIES ************************ Bedside Manner: Advocating for a Relative in the Hospital By MELINDA BECK Don't go to the hospital alone, if you can possibly avoid it. A friend of mine slipped on the sidewalk recently and broke her hip. She had surgery in one of the best hospitals in the country. But it was my friend's grown daughter who noticed that she was having an adverse reaction to a pain medication. And that her IV drip had pulled out of a vein and was pumping her arm full of fluid. And that the hot compresses to reduce the swelling in her arm had left blisters on her skin. And that the blood-sugar test she was about to be given was meant for her roommate instead. Having someone with you in a hospital who is alert and asking questions can help stave off all kinds of potential problems, from mistaken identity to medication mixups to MRSA infections. An estimated 100,000 hospital patients die every year in the U.S. because of preventable errors. Many hospitals are under financial pressures to keep nursing staffs lean. A personal advocate can be a valuable resource. It doesn't have to be a relative -- and it can be more than one person -- as long as they know you and are willing to speak up. "If we could make only one change in health care, it should be to change the notion that families are visitors. Families are allies and partners for safety and quality," says Beverly Johnson, president of the nonprofit Institute for Family-Centered Care, which is leading a movement to involve families more. A growing number of hospitals are doing just that -- including unlimited visiting hours, letting family members accompany patients to procedures and even stay during emergencies. "We're drawing on the strength of the family. They're not out in the waiting room, wondering what's going on," says Pat Sodomka, senior vice president for Patient and Family-Centered Care at MCG Health Inc., which runs a 630-bed hospital in Augusta, Ga. Some hospitals now have nurses give change-of-shift reports at the bedside and encourage families to share observations. "This is a huge cultural change," says Mary Chatman, Chief Nursing Officer of Pitt County Memorial Hospital in Greenville, N.C., which is giving family and patient advisory groups a voice in designing new facilities and interviewing physicians. Initially, some staffers worried that family involvement would take up valuable time, but in the long run, it saves time because doctors have more information, says Ms. Chatman. After MCG Health's neuroscience unit became more family-centered, average length of stay dropped 50% because discharge planning went faster. Patient satisfaction rose, and nursing turnover dropped. Still, it can be difficult for family members to know when to raise an alarm and how. Karen Aydt Curtiss, a market researcher in Lake Forest, Ill., often felt helpless while her 71-year-old father was recovering from a lung transplant in a big teaching hospital in 2005. He was faring well until he fell, hit his head and was made to lie flat until a neurologist could evaluate him. While he waited -- all weekend -- his new lungs filled up with fluid. He developed pneumonia, then a pulmonary embolism and had three MRSA infections. He died seven months after the transplant, having never left the hospital. "I wish I had grabbed the neurologist by the sleeve and dragged him to my father's room," says Ms. Curtiss, who is writing a book on how to help a loved one in the hospital, titled "Someone With You." Among her suggestions: - Ask everyone who enters the room if they've washed their hands and sterilized equipment. Use antibacterial wipes on surfaces. - Ask nurses to read drug orders aloud and make sure they match the patient's ID bracelet. If it's a new medication, ask what it's for and what to expect. - Be alert for pressure wounds, also known as bedsores, particularly in long hospital stays. Put a piece of sheepskin (available at medical-supply stores) under the sheet to provide padding and cut moisture. Make sure patients are moved often, and lifted, not slid, which can damage fragile tissue. - Bring a deck of cards and other games to help patients work their minds and motor skills. - Keep a journal for observations -- especially if you're sharing the watch with others. - Never give a patient medications on your own. - Don't help a patient get in or out of bed by yourself. - Be respectful and appreciative and remember that other patients may have more urgent needs. But don't hesitate to speak up if you have concerns. Says Ms. Sodomka: "You have knowledge that the caregivers just don't have." ========================== Below is a very basic synopsis of the bacteria and how it functions, on a very cursory level. It is not intended to be taken as medical advice. MRSA, which stands for Methacillian resistant Staphylococcus Aureus, is a bacterial infection that can be contracted by direct contact with a person who has active MRSA, (or sometimes, colonized MRSA) or by exposure to droplets emitted from such a person, through coughing or sneezing. MRSA is not airborne, and N95 respirators are not required to protect against infection when visiting a patient with this diagnosis. However, if that person also has pneumonia, which is very common among those infected by MRSA, that is airborne, and droplet precautions and contact precautions are not sufficient. In those situations, it is prudent to seek the advice of a medical professional. Basically, MRSA, which is referred to by the CDC and NIH as USA300, is a bacterium that destroys immune cells. To understand this concept, a little basic background is needed here. Humans have a reticuloendothelial system, or mononuclear phagocytic system, which basically consists of a series of organs and cells that protect the human organism against foreign invaders, such as bacteria, viruses and fungi. White blood cells, or leukocytes, protect against particular invaders. (White cells also include Alpha, Beta and Gamma Globulins, but these generally protect organs, and are not subject of this issue). There are three types of leukocytes; granulocytes, monocytes and lymphocytes. Lymphocytes are either B cells, or T cells. Most have heard of the T4 or CD4 which is the lymphocyte that is affected adversely by HIV. Monocytes produce the macrophage cell, which basically consumes dead cells and tissue, and removes it from the body. Granulocytes exist in three varieties; basophils, neutrophils and eosinophils. Neutrophils emit Cl [chlorine], H2O2 [hydrogen peroxide], and an antimicrobial protein that normally destroys such invading bacteria such as Staphylococcus, which is present in approximately 30% of the US population, either on their dermal layers, or in their mucosa. Staphylococcus Aureus, however, recognizes the danger of the emissions from the neutrophil, and rather than allowing itself to be destroyed by it, it devours or consumes the neutrophil. Thus, the expression, flesh eating bacteria. When staphylococcus Aureus is Methacillian resistant, it does not respond to the broad spectrum antibiotics, such as Penicillins, Cephalosporins, etc. USA300 can also mutate to become Vancomycin resistant, wherein only incision and debredment or amputation options remain. If the bacterium crosses the erythrocyte barrier, and is carried by the erythrocytes into internal organs, death is likely. That is the method by which MRSA destroys human tissue if left untreated. Common treatments include incision and debredment, with antibiotics, or the introduction of Vancomycin, a powerful gram specific antibiotic. Two common types of MRSA have been identified. HA-MRSA and CA-MRSA. HA-MRSA is hospital acquired Methacillian resistant Staphylococcus Aureus, and CA is community associated Methacillian resistant Staphylococcus Aureus. The official medicare website is located at : http://www.medicare.gov/ How to find a prescription plan under medicare: http://www.medicare.gov/MPDPF/Public/Include/DataSection/Questions/MPDPFIntro.asp? version=default&browser=IE%7C6% 7CWinXP&language=English&defaultstatus=0&pagelist=Home&ViewType=Public&PDPYear=2006&M APDYear=2006&MPDPF%5FMPPF%5FIntegrate=N From the looks of it there are 2 types of plans you can join: Plans include HMOs, PPOs, and Private-Fee-for-Service plans. They offer complete Medicare-covered health care, including drug coverage, through a single plan. Most of these plans generally offer extra benefits and lower copayments than the Original Medicare Plan. However, you may have to see doctors that belong to the plan or go to certain hospitals to get services. FROM NORD again: Knowing Your Health History Could Save Your Life Most Americans believe that knowing their family health history can be beneficial, but only about one-third have actually tried to gather and record information about family health, according to a recent study by the U. S. Centers for Disease Control and Prevention (CDC). Furthermore, the discussion of family history between physician and patient typically lasts just a few minutes. "But knowing your family history can save your life," US Surgeon General Richard H. Carmona said at a press conference in November to launch a project known as the Family History Initiative. As part of this project, the Department of Health and Human Services has created a new computerized tool, called "My Family Health Portrait," that can be downloaded at www.hhs.gov/familyhistory/ to help in the process. Francis S. Collins, MD, PhD, director of the National Human Genome Research Institute, noted that all people have genetic abnormalities that make them more susceptible to certain illnesses. Tracking illnesses from one generation of a family to the next can help identify illnesses for which the family is at risk. This may allow family members, working with their physicians, to take steps to reduce their risk. The tool guides users through a series of screens to record information for each family member about six common diseases. Other conditions may also be added. After the information has been collected, a diagram can be printed and shared with a physician. All personal information is maintained on the user's computer. No information is given to the government. Eventually, the tool will be available in both English and Spanish. Also, a print version will be provided to those who call the Federal Citizen Information Center at (888) 878-3256. The federal employees who have worked on this project, from the National Institutes of Health, Surgeon General's office and CDC, hope families will take advantage of being together over the holidays to compile a health history. "It is our hope as families gather this holiday season, they'll take the time to learn-and record-their families' health histories so that they can continue to have years of family gatherings together," said Muin Khoury, MD, director of CDC's Office of Genomics and Disease Prevention. MEDICAID ALERT: Medicare/Medicaid Information regarding insurance with medicare: You automatically qualify for extra help and don't need to apply if you: have Medicare and full coverage from a state Medicaid program that currently pays for your prescriptions. You should join a plan that meets your needs by December 31, 2005 because Medicaid will no longer pay for prescription drugs. If you don't, Medicare will enroll you in a plan effective January 1, 2006 so you don't miss a day of coverage. You can drop the plan or switch to another any time. get help from your state Medicaid program paying your Medicare premiums (belong to a Medicare Savings Program). You should join a plan that meets your needs by December 31, 2005. If you haven't signed up by May 15, 2006, Medicare will enroll you in a plan effective June 1, 2006 so you don't have to pay a penalty. You can drop the plan or switch to another any time. get Supplemental Security Income. You should join a plan that meets your needs by December 31, 2005. If you haven't signed up by May 15, 2006, Medicare will enroll you in a plan effective June 1, 2006 so you don't have to pay a penalty. If Medicare enrolled you in a prescription drug plan, you can switch to another plan one time before December 31, 2006. Appeals Form If you are having trouble with medicare denying your compression garments, contact Bob Weiss. He can help you with your appeal and the form is above. Email Bob at: lymphactivist@aol.com Save Medicare Act 2008 What To Do When Medicare Says 'No' http://www.elderlawanswers.com/resources/article.asp?id=2334&Section=4&state= Your doctor suggested you have a minor operation or procedure, you went ahead and had it done, and now Medicare won't pay for it. What should you do? Appeal. Your provider tells you that your lymphedema compression garments are not covered. What should you do? Appeal. [Added by Bob Weiss] Medicare covers procedures that are deemed medically necessary. "Appealing is easy and most people win so it is worth your while to challenge a Medicare denial," says the Medicare Rights Center, a national nonprofit organization. The denial of coverage may be due, for example, to a simple coding error in your doctor's office. People have a strong chance of winning their Medicare appeal. According to Center, 80 percent of Medicare Part A appeals and 92 percent of Part B appeals turn out in favor of the person appealing. The Medicare Rights Center offers the following tips to maximize your success when appealing your denial: a.. Write "Please Review" on the bottom of your Medicare Summary Notice (MSN), sign the back and send the original to the address listed on your MSN by certified mail or with delivery confirmation. b.. Include a letter explaining why the claim should be covered. c.. When possible, get a letter of support from your doctor or other health care provider explaining why the service was "medically necessary." d.. Save photocopies and records of all communications, whether written or oral, with Medicare concerning your denial. e.. Keep in mind that you only have up to 120 days from the date on the MSN to submit an appeal. The Center notes that the appeals process is slightly different if you are in a private Medicare plan, like an HMO or a PPO. One difference is that you have only 60 days from the date on the denial notice to file an appeal. Resources: For information on how to fight a hospital discharge, click here. For more on the Medicare Rights Center, visit its Web site at http://www.medicarerights.org To download Medicare appeal forms from the government's Medicare website, click here. -------------------------------------------------------------------------------------------- FILING A CLAIM FOR REIMBURSEMENT FOR COMPRESSION GARMENTS * Garment supplier fills out an ABN and gives Beneficiary a copy. Beneficiary pays garment fitter and gets a receipt. Make sure that this is the latest version of Form CMS-R-131. I have the version dated (03/08). This is important since the Section (G) Options were in reverse order from earlier versions. The option to be chosen is the only one which states in bold "I can appeal to Medicare". * If the Supplier should choose to file the claim for the beneficiary, they will file on a Form 1500. Ask that they fill out Item 27 Acceptance of Assignment with a "NO", and further place the note "Beneficiary refuses to assign benefits" in Item 19. (see note below why Supplier may not be motivated to file for the beneficiary). * Beneficiary submits CMS form 1490 Patient's Request for Medical Payment to Medicare requesting reimbursement for the garment listed on the ABN, and attaches receipt. Block 6 Authorization says "... and request payment of medical insurance benefits to me." just above beneficiary's signature. * Medicare sends a denial directly to the Beneficiary. Denial appears on the quarterly Medicare Summary Notice (MSN). After the headers on this form, the sentence "This is a summary of claims processed from ... to ...". Following this there should be a section labeled "Part B Medical Insurance-Unassigned Claims". In the last column "See Notes Section" there will be a series of code letters denoting the reason for the denial. There will also be detailed instructions for appealing the decision. There is a 120-day appeal period after which no appeal will be allowed. * Beneficiary consults Bob Weiss [LymphActivist@aol.com] to proceed further, i.e., several more denials will come down the pike before it goes to an administrative law judge... At this point I will need a copy of the MSN and I will either guide the beneficiary in the first appeal, or I will file it on behalf of the beneficiary. This first appeal to an "independent" Medicare Contractor is called a "Redetermination", the next appeal to a "Medicare Quality Independent Contractor" or a "DME MAC" is a "Reconsideration", and the next appeal is to an Administrative Law Judge (ALJ). None of these appeals costs any more than the cost of making copies and postage. There is a 60-80% chance of a favorable determination by the ALJ. In the event that the ALJ renders an unfavorable decision then we will appeal to the Medicare Appeals Council, where I run about a 50% favorable rate. IF the Beneficiary gets reimbursed after 2 years or so, the ABN states that "If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles." This puzzles me. Does this mean that Medicare will reimburse the garment fitter directly? (That's crazy because it is definintely not in a garment fitter's interest to go to the trouble of submitting an ABN for a Beneficiary only to have to refund their money at a later time). You are correct that the Supplier has little incentive to file your complaint. The supplier receives a reduced amount of reimbursement from the retail price of the item, and if they are a Medicare Supplier they are required to file a claim for something they know will be denied. So they will ask for payment in advance. So as long as they are filing on behalf of the beneficiary it is important for the beneficiary to refuse to assign benefits on the Form 1500. That way there will be no refunds necessary. (Thanks to therapist Kevern Hartmann for providing the framework for this piece and forcing me to research the appeal process. I would ask any reader who discovers any errors or changes to the process to contact me immediately. Please remember that I am not allowed to provide medical or legal advice. All I can do is to read the appropriate regulations and policies and tell you what my understanding is.) Robert Weiss, M.S. Lymphedema Patient Advocate LymphActivist@aol.com -------------------------------------------------------------------------------------------- Abstracted this from an article in the San Francisco Chronicle. This applies to denials of compression bandages, garments and devices, which are medically required in the treatment of lymphedema. Bob Weiss Medical care's state of denial Victoria Colliver, Chronicle Staff Writer Monday, June 23, 2008 http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2008/06/22/MNUK11C28G.DTL&tsp=1 What to do if you are denied medical care If your health insurance carrier is refusing to approve treatment recommended by your doctor, you have a number of options. First, contact your health plan. You probably will have to go through the plan's internal grievance process first. If time is of the essence, ask for an expedited review through the state. Tips to help you get the care you need: -- Review your health plan policy. Many are available online. -- Make sure your doctor is aware of your problem. Sometimes the initial denial comes from the medical group, which is charged with managing costs. In any case, your doctor's support is important. -- Request the reason for the denial in writing. Take detailed notes of all conversations, including the date and time of the call and the name of the person you speak with. Save copies of all paperwork, and keep these records in chronological order. -- Act soon. If you wait longer than six months, you could lose the right to file a complaint, ask for an independent medical review (also called an IMR), or take other action against your health plan such as arbitration or a lawsuit. An IMR decision is binding on the health plan, but not the patient. ------------------------------------------------------------------------------------------- NHIC Provider Education, Medicare Part B Expiration of Therapy Cap Exceptions The exceptions to outpatient therapy caps expire on June 30, 2008. Outpatient therapy service providers should not submit claims with the KX modifier for services furnished on or after July 1, 2008. To the extent possible, CMS is working with Congress, health care providers, and the beneficiary community to avoid disruption in the delivery of health care services and payment of outpatient physical therapy, occupational therapy and speech-language pathology claims for services furnished by physicians, non- physician practitioners, and therapists paid under the physician fee schedule, beginning July 1. For physical therapy and speech language pathology services combined, the limit on incurred expenses is $1810. For occupational therapy services, the limit is $1810. Deductible and coinsurance amounts applied to therapy services count toward the amount accrued before a cap is reached. Therapy cap accruals began on January 1, 2008, and some patients may have reached the annual limits by June 30, 2008. Providers may access the accrued amount or remaining amount of therapy services from the Medicare beneficiary eligibility inquiry and response transactions. Specifically: o For CWF users, the system returns the “applied” amount. See CR4115 at http://www.cms. hhs. gov/transmit tals/downloads/ /R759CP.pdf o For users of the HETS 270/271, the system returns the “remaining” amount. See the page 18 of the 270/271 user guide at http://www.cms. hhs.gov/HETSHelp /Downloads/ HETS%20270- 271%20User% 20Compan ion%20Guide. pdf o The Medicare contractors' Interactive Voice Response units (IVR) return either the remaining or applied amounts based upon contractor programming. For those few contractors that do not provide this information on their IVRs, providers can call the contractors' customer service representatives. For additional information, Providers and Suppliers should also read the Medicare Claims Processing Manual, chapter 5, section 10. 2 at http://www.cms. hhs.gov/manuals/ downloads/ clm104c05TXT. pdf Patients Who Have Reached Their Limit(s) on Outpatient Therapy Services: Note that patients who have reached their limit(s) on outpatient therapy services, other than those who reside in a Medicare-certified part of a skilled nursing facility, may obtain medically necessary therapy services that exceed the caps if the services are furnished and billed by the outpatient department of a hospital. In other settings, outpatient therapy services in excess of the caps are not covered, and the therapy provider may charge for those services. An Advance Beneficiary Notice is recommended, but not required for services that exceed therapy caps. An ABN is available at the following link: http://www.cms. hhs.gov/BNI/ 02_ABNGABNL. asp#TopOfPage (click on ABN-CMS-R-131 Form). In the box titled "Reason Medicare will not pay" the following language is suggested Medicare will not pay more than $1810 for expenses incurred for physical therapy and speech-language pathology services combined or for occupational services in 2008. Patients may be referred to this website for further information: http://www.medicare .gov/Publication s/Pubs/pdf/ 10988.pdf which will be activated by July 3, 2008. We will continue to be in communication with you with further information about payment of Medicare physician fee schedule claims. In addition, be on the alert for more information about other legislative provisions which may affect you. Reference: JSM/TDL-08387; 7/3/2008 ---------------------------------------------------------------------------------- Extension of Therapy Cap Exceptions July 16, 2008 The Medicare Improvements for Patients and Providers Act of 2008 was enacted on July 15, 2008. One provision of this legislation extends the effective date of the exceptions process to the therapy caps to December 31, 2009. Outpatient therapy service providers may now resume submitting claims with the KX modifier for therapy services that exceed the cap furnished on or after July 1, 2008. For physical therapy and speech language pathology services combined, the limit on incurred expenses is $1810 for calendar year 2008. For occupational therapy services, the limit is $1810. Deductible and coinsurance amounts applied to therapy services count toward the amount accrued before a cap is reached. Services that meet the exceptions criteria and report the KX modifier will be paid beyond this limit. Before this legislation was enacted, outpatient therapy service providers were previously instructed to not submit the KX modifier on claims for services furnished on or after July 1, 2008. The extension of the therapy cap exceptions is retroactive to July 1, 2008. As a result, providers may have already submitted some claims without the KX modifier that would qualify for an exception. Providers submitting these claims using the 837 institutional electronic claim format or the UB-04 paper claim format would have had these claims rejected for exceeding the cap. These providers should resubmit these claims appending the KX modifier so they may now be processed and paid. Providers submitting these claims using the 837 professional electronic claim format or the CMS-1500 paper claim format would have had these claims denied for exceeding the cap. These providers should request to have their claims adjusted in order to have the contractor pay the claim. In all cases, if the beneficiary was notified of their liability and the beneficiary made payment for services that now qualify for exceptions, any such payments should be refunded to the beneficiary. --------------------------------------------------------------------------------------- Seven Mistakes to Avoid When Seeking Social Security Disability BenefitsAllsup outlines missteps that can be obstacles when applying for SSDI benefits.Belleville, Ill. (Vocus) July 11, 2008 -- People with severe disabilities know what it means to wait. They wait medical test results; they wait doctors’ diagnoses and they wait for answers to their questions about the future. Delays are typical for people filing for Social Security Disability Insurance (http://allsup.com/About-SSDI/Free-SSDI-Evaluation.aspx) (SSDI) benefits, but there are ways to avoid common mistakes that make the process even more difficult to navigate, according to Allsup (http://allsup.com/Home.aspx). Founded in 1984 and headquartered near St. Louis, Allsup represents people nationwide for their entitled SSDI benefits.Two-thirds of all SSDI applicants will have their initial claim denied. If they appeal, and even if they are successful, they will go through several additional steps and may wait two years or longer before they ev er see a disability payment. There are some missteps, however, that can actually add time and increase the delay for an SSDI award, according to Allsup.“Social Security disability payments are a significant, and often the sole, income source for millions of individuals with disabilities and their families,” said Edward Swierczek (http://www.allsup.com/About- Us/News-Room/Resources-for-Journalists/Allsup-Experts/Edward-Swierczek.aspx), senior claimant representative with Allsup. “Unfortunately, people with disabilities often make mistakes in applying for their SSDI benefits. This may result in even more delays, which puts more stress on what could already be a precarious financial situation.”To help educate claimants, Allsup provides the following information on seven common mistakes people make when filing for SSDI benefits.Seven Common Mistakes When Filing for SSDI1. Going into the process uneducated. Some people believe it’s just a matter of filling out a few forms, sending them in and waiting for their checks. They would be surprised to find out just how complicated the SSDI process really is. The Social Security Administration follows a five-step sequential evaluation process to determine if an individual qualifies for disability benefits (http://allsup.com/About-SSDI/Why-You-Want- SSDI.aspx), explained Swierczek, including:* You must not be gainfully employed, which is defined as earning $940 a month or more, * Your condition is severe, meaning it interferes with basic activities of work, * Your condition is on the Social Security Administration’s list of disabling conditions, or medically equals one of the disabling conditions on the list, and you will be disabled for more than 12 months, * You are not able to do the work you had been doing before the impairment, and, * You can’t perform any other type of work. “You have to meet the first two criteria before the Social Security Administration will consider your claim,” said Swierczek, who has more than 30 years of experience helping individuals through the complexities of the SSDI application process (http://allsup.com/About-SSDI/SSDI-Process.aspx). “If you’re a 40-year-old ironworker who hurt your back, the Social Security Administration may find that you are not disabled if you can do desk work. You may not think you can, but if you don’t provide compelling evidence20why you can’t, they will deny your claim,” he said.2. Going through the SSDI process alone. Individuals who apply for Social Security Disability Insurance benefits (http://www.allsup.com/About- SSDI/Choosing-Representation.aspx) without representation are more likely to have their claim denied. “Working with government agencies and understanding the nuances of what’s needed to comply with the regulation isn’t something the average person is aware of,” said Allsup senior claimant representative David Bueltemann (http://www.allsup.com/About-Us/News-Room/Resources-for-Journalists/Allsup- Experts/David-Bueltemann.aspx), who has successfully represented thousands of SSDI applicants.“Just as people hire accountants to complete their tax returns and represent them before the Internal Revenue Service if they’re audited, individuals are recognizing they need representation when they go into the Social Security Disability Insurance process,” he added.3. Underestimating the impact of your disability. Sometimes pride leads people to underplay the extent of their disabilities because they have endured a condition so long that they have learned how to cope with the stress of daily life. But many people underestima te how much their disability affects their day-to-day lives. A good example, Bueltemann explained, is a 50-year-old grandmother who tells the state Disability Determination Service (DDS) that she takes care of her grandchildren. If the woman doesn’t explain that the children are teen-agers and self- sufficient, the DDS may deny her claim because it believes that she is capable of working in a day care center.4. Exaggerating the impact of your disability. On the other end of the spectrum are people who want to make their condition appear worse than it is. For example, a man who uses a cane at a hearing before an administrative law judge but doesn’t normally use a cane would be over-representing his condition. “If the judge asks to look at the cane and sees the tip is not worn, the claim is immediately suspect, even though the claimant may have had a legitimate case if he’d just stuck to the unexaggerated truth,” Swierczek explained. “It is important to elaborate, but not exaggerate.”5. Being vague about your work history. Knowing what the expectations are for your work, and showing accurately from the outset why you can’t perform this work any longer, is an essential part of qualifying for SSDI benefits (http://www.allsup.com/About- SSDI/SSDI-Guidelines-by-Disability.aspx). For example , Swierczek said, a service technician might be required to drive for extended periods as part of the job. “If your impairment means you can only drive for 10 minutes without experiencing extreme pain, yet your job requires you drive in 60-minute stretches, you need to make it clear on your disability application what the work expectations are and what your limitations are,” said Swierczek. “Otherwise, you may end up in double jeopardy: Your disability claim is rejected because the Social Security Administration believes you can still perform your work,” he said. “But you’re out of work because you really can’t meet the requirements of the job.”6. Missing the appeals deadline. The Social Security Administration denies more than 60 percent of all initial SSDI applications, but there is a formal appeals process with three levels. If you are rejected at any level, you have only 60 days to appeal to the next level. If you miss the deadline, you need to start the process from the beginning. If you’ve applied on your own and received a denial, it’s not too late to choose an SSDI representative (http://www.allsup. com/Allsup-Representation/How-It-Works-At-Allsup.aspx), such as Allsup, to handle the appeal and continue with your case. Taking this step may make the differenc e in experiencing further delays to receiving your SSDI benefits.7. Giving up. The process can be excruciatingly long and cumbersome. Nearly 750,000 people are waiting for a hearing before an administrative law judge, which is only one level of the SSDI appeals process. For individuals already facing significant physical or mental disabilities, this delay can add to the difficulty. Bueltemann, however, is quick to point out that receiving SSDI is a benefit that individuals with disabilities and their families have earned, if they meet the SSDI requirements. An SSDI award also is essential in securing other forms of financial support, including Medicare benefits (http://www.allsup. com/Financial-Matters/Managing-Healthcare-Costs/Medicare.aspx) and retirement protection. “It may not be as easy as it should be to receive your payments, but don’t give up,” Bueltemann said. “Make sure you have good representation and don’t lose hope that you can secure your benefits.”ABOUT ALLSUPAllsup, Belleville, Ill., is a leading nationwide provider of financial and healthcare related services to people with disabilities. Founded in 1984, Allsup has helped more than 100,000 people receive their entitled Social Security Disability Insurance and Medicare benefits. Allsup employs more than 500 professionals who deliver se rvices directly to consumers and their families, or through their employers and long-term disability insurance carriers. For more information, visit www.Allsup.com.Contacts: Allsup - Rebecca Ray(800) 854- 1418, ext. 5065 Dan Allsup, ext. 5760. ---------------------------------------------------------------------------------------- I have no idea if this is good or not, cause if the cap is 1810, my therapy for less than 2 weeks 3 years ago was almost $9,000 so what good is 1810? Well I hope this does help someone out there and that it is a good thing. If you are on Medicare and are provided lymphedema treatment by a Medicare-approved physical therapist, you do not pay (except for deductables and 20% co-pay) for the service up to $1800. The therapist is not alowed to charge any more, and (s)he is reimbursed by Medicare. The reimbursement rates vary from state to state, but run about $25 per unit, with 3-4 units per visit, that provides about 15-20 visits. But this annual limit has been suspended for many years by Congress, but is now back in place. But Congress has also said that in cases where there is a medical necessity for more than the capped amount per year, there would be an exception process for certain conditions. Last year lymphedema was on the list of exception conditions, so the limit did not apply. But starting July 1, the exception process expired. This new law just put the exception process back. That's good, since if you need more than 15-20 treatments in any one year for your lymphedema, you can have them justified. I have no idea how your therapist charged you $9,000 for a course of lymphedema treatment. Did that cost include bandages or garments (not covered by Medicare)? Bob Weiss Lymphedema Patient Advocate ----------------------------------------------------------------------------------- Bob... I just got a new prescription for Compression hose... I have never worn any... I just can't afford them right now.. I had one RX but did not even try to get them because I knew that I could not afford them.. I am on Medicaid.. should I try with this RX and then when I get turned down then try the appeals process or should I wait until I can afford a pair and then try and after I have to pay for them go for an appeal? I really just can't afford them.. I can't afford my treatment at all.. so I am just waiting in limbo right now... It is a little hard to do when I get fluid in my knees and can't stand up on my own at times... any advice???? Thanks, Marbeth :) Marbeth, Find a Medicare approved supplier and give them a copy (you keep the original) of the doctor's prescrition and ask them to request an advanced approval to Medicaid and to Medicare if you are on both. It will be denied, but you will then have something to appeal and a claim number that can be tracked. The prescription should clearly state that the stocking is necessary to treat your lymphedema, with the appropriate diagnostic code. Bob Weiss ---------------------------------------------------------------------------------- By accepting the denial of treatment or a compression garment on the basis of the the letter of denial which says it is not covered, we allow this insurance travesty to continue. Appeal each and every denial of lymphedema treatment. If you run into what appears to be a brick wall contact me and I'll see how to approach an appeal. Bob Weiss Lymphedema Treament Advocate ================================================================= San Francisco Chronicle Examines Health Insurance Claim Denials The San Francisco Chronicle on Monday examined how "[e]ach year, thousands of Californians find themselves at odds with their health insurers over whether they, as patients, should get the treatment their doctors prescribed." Insurers say that physicians do not always prescribe the most cost-effective treatments. Anthem Blue Cross says it follows strict protocols in denying care and relies on medical evidence to determine what care is appropriate. Michael Belman, Anthem's medical director, said, "Even in a dire situation, it is ethically appropriate to withhold treatment if it's not effective." Alan Sokolow, chief medical officer for Blue Shield of California, said, "We think that is our job -- to help patients and providers apply the benefit package the patient has, the dollars they put for insurance coverage and health care, in the most appropriate and effective way," adding that patients should appeal denials if they disagree. According to the Chronicle, in 2007, the state's HMO Help Center received about 90,000 calls from individuals with health insurance disputes. The majority of disputes involved whether treatment or procedures prescribed by physicians were "medically necessary" or considered "experimental" or "investigational." The state Department of Insurance, which regulates a smaller number of insurance plans, received 35,280 complaints and resolved 262 independent medical review cases in 2007. The Department of Managed Health Care since 2001 has offered third-party medical reviews and has resolved 1,716 IMRs since 2007. According to DMHC, roughly 40% of decisions are settled in favor of the patient. Jerry Flanagan, health advocate for Consumer Watchdog, said that issues arise because health insurers "are going back to the old strategies of the '90s, when they interrupted care on the front end by denying or delaying treatment offered by a doctor." He said insurers hope patients will not dispute the decisions or settle for less, in order to save money -- a statement that insurers dispute. The Chronicle also profiled the cases of three individuals whose claims were denied by insurers (Colliver, San Francisco Chronicle, 6/23). ------------------------------------------------------------------------------ Analysis Examines Cost Of Employer-Sponsored Health Coverage; Report Looks At Medicare Part D Plan Changes; More http://www.medicalnewstoday.com/articles/130355.php Connecticut Attorney General Calls For Rebidding Of State Health Insurance Programs, Governor Says Move Is Unnecessary http://www.medicalnewstoday.com/articles/130352.php Michigan Attorney General Says Lawmakers Should Not Pass Health Insurance Legislation In Lame-Duck Session http://www.medicalnewstoday.com/articles/130351.php Average Annual Deductible For Individual Employer-Sponsored PPO Now Over $1,000, According To Survey http://www.medicalnewstoday.com/articles/130349.php AHIP, BCBS Say They Support Guaranteed Coverage For People With Pre-Existing Health Conditions, As Long As All Individuals Required To Obtain Cover http://www.medicalnewstoday.com/articles/130344.php Senate Leaders Hold Closed-Door Meeting To Discuss Health Care Overhaul Legislation http://www.medicalnewstoday.com/articles/130342.php Obama Appoints Former Sen. Daschle As HHS Secretary, Democratic Officials Say http://www.medicalnewstoday.com/articles/130341.php Board Adopts Recommendations To Overhaul Oregon Health Care System http://www.medicalnewstoday.com/articles/130146.php AARP Hires Outside Investigator To Examine Sales Of Limited-Coverage Plans http://www.medicalnewstoday.com/articles/130138.php President-Elect Obama Likely To Pick CBO Director Orszag As Director Of U.S. Office Of Management And Budget http://www.medicalnewstoday.com/articles/130135.php Automaker Bankruptcies Would Require Taxpayers To Pay $3B Annually For Health Care, UAW President Gettelfinger Says http://www.medicalnewstoday.com/articles/130133.php Sen. Kennedy Taps Senators To Lead Various Working Groups Aimed At Improving U.S. Health Care http://www.medicalnewstoday.com/articles/130132.php Several Recent Editorials, Opinion Pieces Address Health Care Reform http://www.medicalnewstoday.com/articles/129958.php New York Times Editorial Calls U.S. Chronic Disease Care 'Abysmal' http://www.medicalnewstoday.com/articles/129956.php Kaiser Daily Health Policy Report Feature Highlights Recent Blog Entries http://www.medicalnewstoday.com/articles/129955.php Connecticut Gov. Rell Keeps HUSKY Kids Insurance Program Separate From Adult Coverage Program http://www.medicalnewstoday.com/articles/129954.php Growing Number Of Companies Provide On-Site Health Care Services For Workers http://www.medicalnewstoday.com/articles/129949.php Coalition Of National Organizations Urges Steps To Reduce Health Care Costs, Improve Quality http://www.medicalnewstoday.com/articles/129948.php Sen. Edward Kennedy Plans To Introduce Universal Health Care Bill http://www.medicalnewstoday.com/articles/129943.php Health Insurance Premiums Rise Up To 33 Percent With State Pricing Rule, USA http://www.medicalnewstoday.com/articles/129802.php Boston Globe Examines Discrepancies In Massachusetts Hospitals' Insurance Reimbursement Payments http://www.medicalnewstoday.com/articles/129763.php New York Attorney General Investigates Relationships Between Colleges, Health Insurers That Cover Students http://www.medicalnewstoday.com/articles/129760.php Wall Street Journal Examines Steep Health Plan Premium Increases For Many Sm Businesses In 2009; New York Times Examines High-Deductible Health Plans http://www.medicalnewstoday.com/articles/129759.php President-Elect Barack Obama, Congressional Democrats Frame Health Care, Other Proposals As Job- Creation Plans http://www.medicalnewstoday.com/articles/129756.php Study Shows Half Of Individual Health Insurance Policy Holders Paid Under $130 Per Month, USA http://www.medicalnewstoday.com/articles/129651.php Briefs Highlight Issues Involving Integration Of Mental Health Services In Health Reform; Statehealthfacts. org Adds New, Updated Data; More http://www.medicalnewstoday.com/articles/129570.php Arizona Rejects Ballot Measure To Make Mandated Health Coverage Illegal http://www.medicalnewstoday.com/articles/129566.php Philadelphia Inquirer Series Examines Health Care Delays For Patients Without Health Insurance http://www.medicalnewstoday.com/articles/129563.php PhRMA To Launch Ad Campaign Lauding Free-Market Health Care System; SEIU Pushes For Health Reform http://www.medicalnewstoday.com/articles/129560.php ------------------------------------------------------------------------------------------------- EE page 11 -- topic 08.71 Garments to be discussed : FLEXITOUCH. We need to continue to contact our local politicians to continue to push for all lymphedema garments expenses to be covered! Thanks Lisa for the heads-up. This request is for Medicare Codes for the body garments used with the Flexitouch pneumatic compression controller. They are coded as "durable medical equipment" since they are used in conjunction with a piece of durable medical equipment. This ruling will in no way affect coverage of compression bandages or garments, which are a different Medicare benefit category (i.e. "prosthetic devices"). I'm afraid that while contacting our local politicians serves a valuable educational function, it will not achieve coverage without either a new law or by forcing CMS to re-interpret the current law. And to do the latter, there must be a ground-swell of appeals from lymphedema patients who are denied coverage for their garments. I will make this offer: If you file a claim for the garments or bandaging kits that you paid for in the last couple of months, when the denial comes from your insurance company or from Medicare, I will help you file the three appeals necessary to reach an Administrative Law Judge. At this point you have a good chance of being reimbursed. I do not charge for this help. I'm trying to get favorable decisions from as many different ALJs as I can. Then I will confront CMS for a change in their interpretation of the Social Security Act. I will also help your Congressional representative draft and introduce a bill to change Medicare, if you can interest him or her in your cause. Robert Weiss, M.S. Lymphedema Treatment Advocate National Lymphedema Network ------------------------------------------------------------------- There have been recent "clarifications" to the "incident to" physician services rules which may impact provision of therapy services for some lymphedema therapists. The changes to the policies are summarized in http://www.cms. hhs.gov/MLNMatte rsArticles/ downloads/ MM5288.pdf with the full-text policy revisions given in http://www.cms. hhs.gov/Transmit tals/downloads/ R87BP.pdf ------------------------------------------------------------------------------------------- Settlement to Ease Drug Costs for Some on Medicare By ROBERT PEAR http://www.nytimes.com/2008/06/20/health/policy/20drug.html?_r=1&ref=health&oref=slogin Published: June 20, 2008 WASHINGTON - The Bush administration promised on Thursday to provide new protections for low-income Medicare beneficiaries to ensure they can get prescription drugs promptly, at minimal cost. The promise came in the proposed settlement of a nationwide class-action lawsuit filed on behalf of hundreds of thousands of people who have had difficulty getting the medicines they need. Under the 2003 Medicare law, more than six million people eligible for both Medicare and Medicaid are entitled to extra help with their drug costs. But in many cases, they could not get the assistance, so they did not receive the drugs they needed, or they experienced long delays. In early 2006, low-income beneficiaries were often overcharged, and some were turned away from pharmacies without getting their medications. Several states declared public health emergencies, and many stepped in to pay for prescriptions that should have been covered by the federal Medicare program. Under the proposed settlement, filed Thursday with the United States District Court in San Francisco, federal Medicare officials promised to speed up the process of providing extra help to low-income people, who now could qualify within days, rather than weeks or months. Drug benefits are delivered by private insurers under contract to Medicare. Under the settlement, these insurers will have to provide medications at minimal cost for any Medicare recipients who prove they have low incomes and qualify for extra help. For most people with incomes less than the poverty level ($10,400 a year for an individual), the maximum co-payment is $1.05 for a generic or preferred brand-name drug and $3.10 for other prescription drugs. But many beneficiaries have been asked to pay much higher amounts, from $30 to $75 or more, because the evidence of their low-income status was not properly shared among federal and state agencies, insurance companies and pharmacies. "This settlement agreement is a victory for many of the nation's most vulnerable citizens, who have faced life-threatening delays in obtaining vital medications," said Kevin Prindiville, a lawyer at the National Senior Citizens Law Center, which filed the lawsuit with another nonprofit group, the Center for Medicare Advocacy. Gill Deford, a lawyer at the Center for Medicare Advocacy, said the settlement would "help hundreds of thousands of people a year get their prescription drugs more quickly, at nominal cost." Jeff Nelligan, a spokesman for the federal Centers for Medicare and Medicaid Services, said federal officials had "worked tirelessly" to ensure that Medicare recipients could fill their prescriptions. He refused to comment on the substance of the settlement, noting that it was subject to approval by Judge Thelton E. Henderson of Federal District Court in California. States administer the Medicaid program. They have crucial information showing whether Medicare beneficiaries are also enrolled in Medicaid and therefore eligible for extra help with their drug costs. Under the settlement, if a beneficiary claims to be eligible for the low-income subsidy but does not have the documents to prove it, and if the person is about to run out of a medication, federal officials would immediately contact the state Medicaid agency to check whether the person had been on Medicaid. -------------------------------------------------------------------------------- News from New York State Assemblyman ALAN N. MAISEL 59th ASSEMBLY DISTRICT Date: June 23, 2008 Assembly Passes Maisel Measure To Raise Awareness of Lymphedema Today, in Albany, Assemblyman Alan Maisel (D-Kings County) announced passage in the Assembly of legislation to promote lymphedema and lymphatic disease reporting and awareness (A05892B). TThe measure requires health care providers, who are already required to report cases of cancer or oother malignant disease, to also report instances of lymphedema related to cancer treatment in their patients. This legislation also requires the Department of Health to develop a health care and wellness education and outreach program for those seeking information on either primary or secondary lymphedema. "Lymphedema is not a high profile disease like cancer or diabetes that generates a lot of press or mmoney for research, yet it affects an estimated six million men, women and children in the United States," stated Maisel. "The lymphatic system is vital to the health of every individual as it is an integral part of tthe immune system.” Lymphedema is an accumulation of lymphatic fluid that causes painful, disfiguring sswelling, usually in the arms or legs. There are two major types of lymphedema: primary (congenital) and ssecondary (caused by tissue injury, scarring, lymph node removal, or infection). "The largest group of people who acquire secondary lymphedema arc cancer patients, including those with breast, prostate, lung, and melanoma patients," stated Maisel. "This bill helps to ensure that when lymphedema is acquired from the life-saving cancer treatments, these instances of disease are also rreported to the cancer registry. This will help raise awareness of the disease and hopefully increase the mmoney raised to fund additional research to help find the cause of and cure for lymphatic diseases, lymphedema, and related disorders." "It amazes me that despite the essential role the lymphatic system plays in human health, awareness, education and research have been relatively neglected," stated Maisel. "This lack of focus has created barriers to effective delivery of health care and public education about these diseases, its diagnosis, treatment, therapy and long-term care. This legislation, which is on third reading in the Senate, is just the first step in raising public awareness about lymphedema." ======================================================================= To lymphedema patients, therapists and activists: A wonderful article on lymphedema was printed in the prestigious cancer journal "CA A Cancer Journal for Clinicians" [CA Cancer J Clin 2009;59;8-24] written by by Brian D. Lawenda, Tammy E. Mondry and Peter A. S. Johnstone. "Lymphedema: A primer on the identification and management of a chronic condition in oncologic treatment" can be downloaded from URL <http://caonline.amcancersoc.org/cgi/reprint/59/1/8> An accompanying description of lymphedema and its treatment can also be downloaded at the same source from URL <http://caonline.amcancersoc.org/cgi/content/full/59/1/25> I urge all of the readers of this message to download these references, print them out, and bring copies to your physicians, oncologists, and medical and insurance staffs. This is a well written and authoritative reference which should be brought to the attention of all medical providers and insurers. Robert Weiss, M.S. Lymphedema Treatment Advocate National Lymphedema Network ======================================================================= Written Clarification on Medicare for Patients and Providers Act of 2008 (MIPPA) MIPPA section 154(b) added a new subparagraph (F) to section 1834(a)(20) of the Social Security Act. This subparagraph states that eligible professionals and other persons are exempt from meeting the September 30, 2009 accreditation deadline that generally applies to other DMEPOS suppliers unless CMS determines that the quality standards are specifically designed to apply to such professionals and persons. The eligible professionals to whom this exemption applies are set out at sections 1848(k)(3)(B) and 1861(r) of the Act, and include Physicians, Physical Therapists, Occupational Therapists, Qualified Speech- Language Pathologists, Physician Assistants, and Nurse Practitioners. Additionally, section 154(b) of MIPPA allows the Secretary to specify “other persons” that, like the eligible professionals described above, are exempt from meeting the accreditation requirements unless CMS determines that the quality standards are specifically designed to apply to such other persons. At this time, we are defining “such other persons” as Orthotists, Prosthetists, Opticians, and Audiologists. CMS will define how the quality standards apply to these eligible professionals and other persons by rulemaking in 2009. Individuals not included in this exemption list, such as pedorthotists, mastectomy fitters, orthopaedic fitters/ technicians or athletic trainers applying for Medicare enrollment in order to bill for Medicare part B services are not exempt from meeting the September 30, 2009 deadline for DMEPOS accreditation. ----------------------------------------------------------------- New HCPCS Codes The following new codes are effective for dates of service on or after January 1, 2009. If billed before January 1, 2009, the code will be returned as unprocessable or denied as an invalid code. The appearance of a HCPCS code in the list below does not necessarily indicate coverage. HCPCS Code Description A6545 GRADIENT COMPRESSION WRAP, NON-ELASTIC, BELOW KNEE, 30-50 MM HG, EACH E0656 SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, TRUNK E0657 SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, CHEST Verbiage Changes for 2008 The following list contains HCPCS codes for which verbiage will be changed effective January 1, 2009. L4360 WALKING BOOT, PNEUMATIC AND/OR VACUUM, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT ======================================================================= December 05, 2008 The Advance Beneficiary Notice of Noncoverage (ABN) and Correct Use of Modifiers GA and GY - Revised Both Medicare beneficiaries and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) suppliers have certain rights and protections related to financial liability under the Fee-for- Service (FFS) Medicare program. These financial liability and appeal rights and protections are communicated to beneficiaries through Advance Beneficiary Notices of Noncoverage (ABN) given by suppliers. An ABN is a written notice the supplier gives to a Medicare beneficiary before providing items and or services that are expected to be denied by Medicare based on one of the following statutory exclusions: 1. The item or service may be denied as "not reasonable and necessary" pursuant to Section 1862(a)(1) of the Social Security Act 2. The item or service may be denied due to an unsolicited telephone contact pursuant to Section 1834(a) (17)(B) 3. The supplier number requirements not being met pursuant to Section 1834(j)(1) 4. Denial of a request for Advance Determination of Medicare Coverage (ADMC) pursuant to Section 1834(a)(15) When an item or service is provided to a Medicare beneficiary and is expected to be denied based on one of the four exclusions listed above, it is the responsibility of the supplier to notify the beneficiary in writing through the use of the ABN before the item or service is delivered or purchased. If the supplier issues a properly executed ABN with Option 1 selected by the beneficiary, the DMEPOS supplier must submit the claim to Medicare using the GA modifier on each Healthcare Common Procedural Coding System (HCPCS) code that is expected to be denied. The GA modifier indicates that the supplier has a waiver of liability statement on file. Statutorily Excluded Items The GY modifier indicates that an item or service is statutorily excluded or does not meet the definition of any Medicare benefit. Some local coverage determinations (LCD) require the use of the GY modifier when the item or service may be excluded from coverage. In this situation, suppliers are instructed to code the claim with the appropriate HCPCS code indicated in the LCD and append the GY modifier. Some examples of statutory exclusions where the GY modifier is required per policy would include: • An infusion drug not administered using a durable infusion pump • A wheelchair that is for use for mobility outside the home To determine if an exclusion of Medicare benefits exist, suppliers must review the applicable LCD and policy article for the item or service being provided. Suppliers are reminded that modifiers GA and GY should never be coded together on the same line for the same HCPCS code. It is important to distinguish situations in which an item is denied because it is statutorily excluded or does not meet the definition of any Medicare benefit from those situations in which at item is denied because it is not reasonable and necessary. Some examples of statutorily excluded items or situations include, but are not limited to: • eyeglasses or contact lenses-except those provided following cataract removal or other cause of aphakia; • Durable Medical Equipment and related accessories and supplies provided to patients in nursing facilities; • personal comfort items; and • orthopedic shoes or shoe inserts-other than those covered under the therapeutic shoes for diabetics benefit or those that are attached to a covered leg brace. Some examples of items or situations which do not meet the definition of a Medicare benefit include, but are not limited to: • Parenteral or enteral nutrients that are used to treat a temporary (rather than permanent) condition; • Enteral nutrients that are administered orally; • Infusion drugs that are not administered through a durable infusion pump; • Surgical dressings that are used to cleanse a wound, clean intact skin, or provide protection to intact skin; • Irrigation supplies that are used to irrigate the skin or wounds; • Immunosuppressive drugs when they are used for conditions other than following organ transplants; • Most oral drugs; • Oral anticancer drugs when there is no injectable or infusion form of the drug; • Nondurable items (that are not covered under any other benefit category); • e.g., compression stockings and sleeves; • Durable items that are not primarily designed to serve a medical purpose; • e.g., exercise equipment. To access the LCDs and policy articles, please visit the DME MAC A Web site at: http://www. medicarenhic.com/dme click on the LCDs/Medical Policies link in the left hand navigation under Medical Review. Voluntary Notification Under the new instruction for the revised ABN, the Centers for Medicare & Medicaid Services (CMS) advise that this form may be used to voluntarily notify Medicare beneficiaries of an expected noncovered denial of Medicare payment due to the statutory exclusion of an item or service, or the item or service not meeting the definition of any Medicare benefit. Section 1848(g)(4) of the Social Security Act states that items that are categorically excluded from Medicare benefits (i.e. hearing aids, personal comfort items, etc.) are not required to be submitted to the Medicare program by the supplier. However, if the beneficiary requests the supplier to submit the claim to Medicare, the claim should be coded with the designated HCPCS, however, neither modifiers GA nor GY are required. The supplier and the Medicare beneficiary will receive a patient responsibility denial for the noncovered services. For additional instruction regarding the proper execution of an ABN, suppliers are encouraged to review the CMS Internet-Only Manual Medicare Claims Processing Manual, Chapter 30, "Financial Liability Protections," Sections 50 and 60 at: http://www.cms.hhs.gov/manuals ======================================================================== ==================== The official Medicare Contractor or Supplier position is that compression garments are not covered. In fact the policy explicitly states: • Nondurable items (that are not covered under any other benefit category); • e.g., compression stockings and sleeves; But recent Administrative Law Judge decisions are that these compression garments DO meet the statutory definition of "prosthetic devices" when they are used in the compression therapy for lymphedema, and ARE covered. But until the policies are rewritten Beneficiaries are forced to pay in advance, sign an ABN Form, and make an appeal of the denied claim. Under these conditions note that the Medicare Supplier MUST file a claim. I am available to help Beneficiaries with their appeals of denied claims. Robert Weiss, M.S. Lymphedema Patient Advocate National Lymphedema Network LymphActivist ------------------------------------------------------------ The bottom line is that compression bandage systems and compression garments remain NON-COVERED in the treatment of lymphedema in the absense of an open venous stasis ulcer. A new CircAid garment has been added to the HCPCS Coding but this below-the-knee device is covered only in the presence of an open venous ulcer. Revisions to the Surgical Dressing LCD effective January 1, 2009 in the following states: Connecticut District of Columbia Delaware Massachusetts Maryland Maine New Hampshire New Jersey New York - Entire State Pennsylvania Rhode Island Vermont Surgical Dressings LCD for Surgical Dressings (L11471) Revision Effective Date: 01/01/2009 INDICATIONS AND LIMITATIONS OF COVERAGE: Added: Frequency of replacement for compression wrap (A6545). Coverage of a non-elastic gradient compression wrap (A6545) is limited to one per 6 months per leg. Quantities exceeding this amount will be denied as not medically necessary. Refer to Policy Article for statement concerning noncoverage if the ulcer has healed. LIGHT COMPRESSION BANDAGE (A6448-A6450), MODERATE/HIGH COMPRESSION BANDAGE (A6451, A6452),SELF-ADHERENT BANDAGE (A6453-A6455),CONFORMING BANDAGE (A6442-A6447), PADDING BANDAGE (A6441): Light compression bandages, self-adherent bandages, and conforming bandages are covered when they are used to hold wound cover dressings in place over any wound type. Moderate or high compression bandages, conforming bandages, self-adherent bandages, and padding bandages are covered when they are part of a multi-layer compression bandage system used in the treatment of a venous stasis ulcer. All of these bandages are noncovered when used for strains, sprains, edema, or situations other than as a dressing for a wound. GRADIENT COMPRESSION STOCKINGS/WRAPS (A6531, A6532, A6545): A gradient compression stocking described by codes A6531 or A6532 or a non-elastic gradient compression wrap described by code A6545 is covered when it is used in the treatment of an open venous stasis ulcer. Codes A6531, A6532, and A6545 are noncovered for the following conditions: venous insufficiency without stasis ulcers, prevention of stasis ulcers, prevention of the reoccurrence of stasis ulcers that have healed, treatment of lymphedema in the absence of ulcers. In these situations, since there is no ulcer, the stockings/wraps do not meet the definition of a surgical dressing. Gradient compression stockings described by codes A6530, A6533-A6544, A6549 and surgical stockings described by codes A4490-A4510 are noncovered for all indications because they do not meet the definition of a surgical dressing. A nonelastic binder for an extremity (A4465) is noncovered for all indications because it does not meet the definition of a surgical dressing. HCPCS CODES AND MODIFIERS: Added: A4490-A4510, A6545. GRADIENT COMPRESSION WRAP (A6545): [This is a Knee length CircAid used in the treatment of an open venous stasis ulcer.] Coverage of a non-elastic gradient compression wrap (A6545) is limited to one per 6 months per leg. Quantities exceeding this amount will be denied as not medically necessary. Refer to Policy Article for statement concerning noncoverage if the ulcer has healed. Revised: A6010-A6024, A6196-A6199, A6203-A6215, A6219-A6248, A6251-A6266, A6407. APPENDICES: Revised: Definitions of pressure ulcer stages. SOURCES OF INFORMATION AND BASIS FOR DECISION: Added: Reference to NPUAP guidelines for pressure ulcer staging. Article for Surgical Dressings - Policy Article - Effective January 2009 (A23664) Revision Effective Date: 01/01/2009 NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES: Clarified: Allowance for HCPCS codes which use the term “kit”. Added: Coverage statements for compression wraps (A6545). The only products that may be billed with code A6545 (non-elastic compression wrap) are those which have received a written Coding Verification Review from the Pricing, Data Analysis, and Coding (PDAC) contractor and that are posted in the Product Classification List on the PDAC web site. Added: Noncoverage statement for surgical stockings (A4490-A4510). CODING GUIDELINES: Added: Requirement for PDAC Coding Verification Review for non-elastic compression wraps (A6545). Revised: Changed SADMERC to PDAC. ========================================================== The above all applies to coverage and coverage criteria created by the Social Security Act, Title XVIII, section 1861(s)(5) Surgical Dressings. Lymphedema compression bandages, garments and devices functionally meet the definition of the Social Security Act, Title XVIII, section 1861(s)(8) Prosthetic Devices, and do not have to meet the coverage criteria for surgical dressings. The undersigned is not empowered to interpret Medicare statute or Medicare policy, but the above statements based on my reading of the relevant statutes and CMS policies are my opinion, and have been validated by eight U.S. Medicare Administrative Law Judges in ten separate Medicare Appeals. Robert Weiss, M.S. Lymphedema Patient Advocate National Lymphedema Network ----------------------------------------------------------------- A revision to the LCD for Pneumatic Compression Devices (L11503) becomes effective on January 1, 2009 affecting the following states: Connecticut District of Columbia Delaware Massachusetts Maryland Maine New Hampshire New Jersey New York - Entire State Pennsylvania Rhode Island Vermont Pneumatic Compression Devices LCD L11503 Revision Effective Date: 01/01/2009 INDICATIONS AND LIMITATIONS OF COVERAGE: Added: Statement regarding appliances for the chest and trunk. HCPCS CODES AND MODIFIERS: Added: E0656 and E0657: E0656 SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, TRUNK E0657 SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, CHEST Article for Pneumatic Compression Devices - Policy Article - Effective January 2009 (A37216) Revision Effective Date: 01/01/2009 CODING GUIDELINES: Changed: References from SADMERC to PDAC. References from DMERC to DME MAC. ================================================================== Physician’s Letter and Certificate of Medical Necessity July 30, 2002 Mrs. Jane Patient 555-55-5555 DOB: 06/14/1942 Patient Diagnosis: Chronic Intractable Lymphedema of the left lower extremity. Her condition is marked by severe 4+ edema of the left lower extremity, weeping wounds, and pain affecting mobility. The tissue is hard and fibrotic. There is no discoloration. Mrs. Patient recalled her mother having difficulty with lower extremity edema, although she was never diagnosed with Lymphedema. Mrs. Patient began to experience lower extremity edema about ten years ago, after undergoing a hysterectomy, at which time a lower abdominal, hip-to-hip incision was made, possibly interrupting the inguinal lymphatics. Patient History: Mrs. Patient is also diagnosed with diabetes, and is Insulin dependent. Surgical History: Hysterectomy, October 11, 1992. Laproscopic Gall Bladder Surgery, February, 1972. Complications Resulting From Lymphedema: In 1996, Mrs. Patient was treated with oral antibiotics for cellulitis. In January, 2002, Mrs. Patient was hospitalized for 14 days for cellulits, and weeping wounds. Previous Treatment: Elevation 01/93 to present no results Exercise 01/93 to present no results Diuretics 01/93 to present no results Graduated Compression Stockings 01/93 to present no results MLD and Physical Therapy 03/01 to 04/01 minimal results Compression Bandaging 03/01 to 04/01 minimal results Unna Boots after January 2002 hospitalization for three months. Dressing changed weekly. No results. At this time I am ordering a Bio Compression Gradient Sequential Compression Device to be used at 55mmHg for 2 hours BID for the remainder of her lifetime. This device will apply gradient sequential compression, on a thirty second cycle, thus pushing the excess fluid back into the vascular system for removal from the body. She is also to wear the OptiFlow SC during compression therapy and for nighttime compression. A Gradient pump is required for Mrs. Patient as she is unable to tolerate the uniform compression, and long cycle times, which is delivered by the standard sequential pumps. If her condition is not treated effectively, she is at risk of her condition worsening, re-occurring cellulitis, chronic weeping wounds, resulting in possible multiple hospitalizations. Prognosis: Good with effective treatment. If you have any questions, please contact me at 702-555-5555. Sincerely, Dr. Joe Doctor, M.D. What to do when your health plan denies your claim If your health insurance company denies your claim and you believe the treatment should be covered, first check your policy to see what benefits your plan provides. The Patient Bill of Rights requires the policy to contain a description of the appeals process. Be sure to send your letter of appeal by registered mail and have the receipt returned to the address listed in the policy. ================================================================= Insurance Information INSURANCE COVERAGE TOOLS I have compiled some healthcare insurance codes and healthcare conditions as relating to Lymphedema coverage. PLEASE NOTE, These conditions, codes, rulings etc are different from state to state, insurance plan to inusurance plan and are constantly changing. Proper documentation and codes may be crucial in getting treatment covereage. Please check with your insurer on the requirements and restrictions as it concerns lymphedema treatment. The codes and medical language should be an asset to your physician or therapist in putting together the request for treatment/therapy coverage or appealing a declination. Conditions For Insurance Coverage (taken from various state medicare sources sources): This coverage policy was developed to provide medical necessity guidelines for complex decongestive physiotherapy for lymphedema. 1. There is a physician documented diagnosis of lymphedema: and the physician specifically orders CDP 2. The patient is symptomatic for lymphedema, with limitation of function related to self care, mobility and/or safety. 3. The patient or patient caregiver has the ability to understand and comply with home care continuation of treatment regimen. 4. The services are being performed by a health care professional who has received specialized training in this form of treatment. ICD-9 diagnosis codes: 457.0 - Post-mastectomy Lymphedema Syndrome 457.1 - Other lymphedema 757.0 - Hereditary edema of the legs (congenital lymphedema) CPT Codes: 97001 - Physical therapy evaluation 97002 - Physical therapy re-evaluation 97003 - Occupational therapy evaluation 97004 - Occupational therapy re-evaluation 97110 - Therapeutic procedure, one or more areas, each 15 minutes: therapeutic exercises to develop strength and endurance, range of motion and flexibility 97140 - Manual therapy techniques (e.g. mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes 97535 - Self-care/home management training (e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of adaptive equipment)direct one on one contact by provider, each 15 minutes Current Facts on Lymphedema in the United States Lymphedema is not a widely discussed condition as many in the medical field are actually quite blind to its seriousness. That having been said, the situation has begun to improve as more and more doctors and health care professionals are beginning to recognize the importance of properly treating this condition. Though insurance companies have been rather slow on the uptake, lymphedema treatments are fast becoming a respected field of medical practice. Every year millions of American find themselves suffering from lymphedema. Some of these cases are primary in nature but the overwhelming majority are acquired after surgery or radiation for specific types of cancer; any type of surgery that removes lymph nodes (like breast cancer surgery) could result in lymphedema. Fortunately, doctors are beginning to wise up and send afflicted patients to lymphedema therapists so they can get the help that they need. Personal devices and services Businesses are not required to provide personal devices (such as wheelchairs) , individually prescribed devices (such as eyeglasses or hearing aids), or services of a personal nature (such as assistance in eating, toileting, or dressing), to customers with disabilities. A business may choose to provide services like this as a way to attract customers. For example, some large retail stores provide electric carts for use by customers while shopping. Some fancy dress shops provide assistance for a customer trying on clothes in the dressing room. The ADA does not require these services; it leaves it up to the business to decide what services it wants to provide. The ADA simply says a business should provide the same goods and services to all of its customers, including those with disabilities. -------------------------------- For those readers who have the military health insurance offered by Tricare For Life and turn 65, the coordination of the TFL and Medicare can become confusing. California Health Advocates has issued an informative Information sheet for you. It can be found on URL: http://www.cahealthadvocates.org/_pdf/facts/F-002-CHAFactSheet.pdf Bob Weiss --------------------------------- The following website has been set up by America's Health Insurance Plans (AHIP) to help consumers through the administrative maze of their healthcare provider. It provides great common-sense information to help you with your appeal of denied medical treatment, and leads you to state insurance sites which can help you file a complaint with your state if you get no satisfaction from your provider. http://www.healthclaimappeals.org/ Bob Weiss Robert Weiss, M.S.Lymphedema Patient Advocate ===================================================================== To Lymphedema Therapists in CA, NV and HI: There are two draft local coverage determinations (LCDs) of interest to the lymphedema community which are being made available by Palmetto GBA for comment. Palmetto is the Medicare Part A/B Jurisdiction 1 Contractor responsible for issuing the LCDs which govern Medicare treatment and billing policy, and which affect reimbursements and allowable treatment. These two LCDs are for Outpatient Physical Therapy (DLCD #28689) and Outpatient Occupational Therapy (DLCD #28691). They are available from the Palmetto web page or I can send a .pdf file to interested persons who wish to read and comment. The comment period is from March 6, 2009 to April 20, 2009. There will be a number of Open Meetings to discuss these two LCDs and a number of other draft LCDs, but the meetings are only 2 hours long and I would advise submitting comments and evidence before the meetings so that they are sure to be considered. Comments are sent to: Palmetto GBA, Attention Part A J1 Medical Affairs, P.O.Box 1437, Augusta, GA 30903-1437. Email Part A comments to J1A.Policy@Palmetto GBA.com Palmetto GBA, Attention Part B J1 Medical Affairs, P.O.Box 1476, Augusta, GA 30903-1476. Email Part B comments to J1B.Policy@Palmetto GBA.com The Part A and Part B LCDs are the same, so I don't know whether it matters which address the comments are sent to. The open meetings scheduled are as follows: Hawaii: March 5, 2009 8-10AM @ The Queens Medical Center, 1301 Punchbowl Street, Conference Room 203, Honolulu, HI 96813; Nevada: March 12, 2009 9-11AM @ Clark County Medical Association, 2590 E. Russell Road, Las Vegas, NV 89120; California: March 17, 2009 9-11AM @ Prostate Cancer Research Institute, 5777 W. Century Blvd., Suite 800, Los Angeles, CA 90045. I will be attending the California meeting and submitting comments. There is a registration process for these meetings on the Palmetto web page. There are a number of issues I have noted which I plan to comment on and make suggestions for changes. These issues include: A. Omission of a number of medical diagnoses which are treated with MLD but which are not included in the list of diagnoses which support treatment. These include codes for hereditary LE of the lower limbs, localized swelling, edema of the eyelid, penis, breast and vulva, vericose veins with edema, etc. B. Vasopneumatic Device Therapy is indicated for lymphedema of the extremity, and should probably include lymphedema of the torso now that a number of pump manufacturers have body garments, and the body garments have separate HCPCS codes (but are not yet covered). C. Manual Decongestive Therapy is described to "reduce lymphedema of extremity" and should not be limited to the extremity. See A above. D. Some clarification is needed for billing for education on exercise. E. Fitting of compression garments is not mentioned. F. It is not clear which protocol (if any) might include education on wearing and care for compression garments, specialized exercises, use of lasers, etc. I'm sure that the therapists who read this note will have many additional clarifications they'd like to have made. Send them to me and I'll try to include them in the document I will be submitting at the Open Meeting.. Robert Weiss, MS Lymphedema Patient Advocate ================================================================ Personal devices and services Businesses are not required to provide personal devices (such as wheelchairs) , individually prescribed devices (such as eyeglasses or hearing aids), or services of a personal nature (such as assistance in eating, toileting, or dressing), to customers with disabilities. A business may choose to provide services like this as a way to attract customers. For example, some large retail stores provide electric carts for use by customers while shopping. Some fancy dress shops provide assistance for a customer trying on clothes in the dressing room. The ADA does not require these services; it leaves it up to the business to decide what services it wants to provide. The ADA simply says a business should provide the same goods and services to all of its customers, including those with disabilities. -------------------------------- For those readers who have the military health insurance offered by Tricare For Life and turn 65, the coordination of the TFL and Medicare can become confusing. California Health Advocates has issued an informative Information sheet for you. It can be found on URL: http://www.cahealthadvocates.org/_pdf/facts/F-002-CHAFactSheet.pdf Bob Weiss --------------------------------- The following website has been set up by America's Health Insurance Plans (AHIP) to help consumers through the administrative maze of their healthcare provider. It provides great common-sense information to help you with your appeal of denied medical treatment, and leads you to state insurance sites which can help you file a complaint with your state if you get no satisfaction from your provider. http://www.healthclaimappeals.org/ Bob Weiss Robert Weiss, M.S.Lymphedema Patient Advocate ================================================================= Current Facts on Lymphedema in the United States Lymphedema is not a widely discussed condition as many in the medical field are actually quite blind to its seriousness. That having been said, the situation has begun to improve as more and more doctors and health care professionals are beginning to recognize the importance of properly treating this condition. Though insurance companies have been rather slow on the uptake, lymphedema treatments are fast becoming a respected field of medical practice. Every year millions of American find themselves suffering from lymphedema. Some of these cases are primary in nature but the overwhelming majority are acquired after surgery or radiation for specific types of cancer; any type of surgery that removes lymph nodes (like breast cancer surgery) could result in lymphedema. Fortunately, doctors are beginning to wise up and send afflicted patients to lymphedema therapists so they can get the help that they need. ================================================================ Insurance Information INSURANCE COVERAGE TOOLS I have compiled some healthcare insurance codes and healthcare conditions as relating to Lymphedema coverage. PLEASE NOTE, These conditions, codes, rulings etc are different from state to state, insurance plan to inusurance plan and are constantly changing. Proper documentation and codes may be crucial in getting treatment covereage. Please check with your insurer on the requirements and restrictions as it concerns lymphedema treatment. The codes and medical language should be an asset to your physician or therapist in putting together the request for treatment/therapy coverage or appealing a declination. Conditions For Insurance Coverage (taken from various state medicare sources sources): This coverage policy was developed to provide medical necessity guidelines for complex decongestive physiotherapy for lymphedema. 1. There is a physician documented diagnosis of lymphedema: and the physician specifically orders CDP 2. The patient is symptomatic for lymphedema, with limitation of function related to self care, mobility and/or safety. 3. The patient or patient caregiver has the ability to understand and comply with home care continuation of treatment regimen. 4. The services are being performed by a health care professional who has received specialized training in this form of treatment. ICD-9 diagnosis codes: 457.0 - Post-mastectomy Lymphedema Syndrome 457.1 - Other lymphedema 757.0 - Hereditary edema of the legs (congenital lymphedema) CPT Codes: 97001 - Physical therapy evaluation 97002 - Physical therapy re-evaluation 97003 - Occupational therapy evaluation 97004 - Occupational therapy re-evaluation 97110 - Therapeutic procedure, one or more areas, each 15 minutes: therapeutic exercises to develop strength and endurance, range of motion and flexibility 97140 - Manual therapy techniques (e.g. mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes 97535 - Self-care/home management training (e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of adaptive equipment)direct one on one contact by provider, each 15 minutes Surgical Dressings Billing Instruction for HCPCS Code A6545 Recent revisions to the Local Coverage Determination (LCD) for Surgical Dressings and the related Policy Article were published with an effective date of January 1, 2009. The Policy Article revision neglected to include billing instructions for HCPCS Code A6545. HCPCS Code Description A6545 Gradient compression wrap, non-elastic, below knee 30- 50 MM HG, each Similar to codes A6531 and A6532 (compression stockings) which are addressed in the Policy Article Coding Guidelines section, HCPCS modifiers A1-A9 are not to be used with A6545. When a gradient compression wrap, A6545, is used for an open venous stasis ulcer, the code must be billed with the AW modifier. If there is no open ulcer, the AW modifier must not be used. Claims for code A6545 without an AW modifier will be denied as statutorily noncovered. The right (RT) and left (LT) modifiers must also be used with this code. When the same code for bilateral items (left and right) is billed on the same date of service, bill both items on the same claim line using LTRT modifiers and 2 units of service. These guidelines will be included in a future revision of the Surgical Dressings medical policy. The only products that may be billed with code A6545 (non-elastic compression wrap) are those which have received a written Coding Verification Review from the Pricing, Data Analysis, and Coding (PDAC) contractor and that are posted in the Product Classification List on the PDAC Web site. Suppliers should review the entire Surgical Dressings LCD and related Policy Article at http://www. cignagovernmentservices.com/ jc/coverage/LCDinfo.html for additional guidance on the coverage, coding and documentation requirements. =================================== Comments to the above clarification: These billing notes are based on coverage criteria for surgical dressings, covered by §1861(s)(5) of the Social Security Act. They are based on the requirements for the surgical dressing benefit category that requires there be an open debridable wound. It is my contention, disputed by Medicare Contractors, that when used to treat lymphedema, a compression wrap is covered by the requirements of §1861(s)(8) prosthetic devices, and need not meet the coverage criteria for surgical dressings--a different benefit category. Furthermore, Medicare policy is that HCPCS coding does not determine coverage, and cannot be used to establish or deny coverage, so any argument that the A-group coding means that it id denied in any other benefit group other than surgical dressings is an invalid statement, in my humble opinion. The above comments are not the opinions of Medicare, and are not to be construed as medical or legal advice. They are my own opinions, validated by approximately 10 Administrative Law Judges in hearings in a dozen individual Medicare hearings. Robert Weiss, MS Lymphedema Patient Advocate ----------------------------------------------- Medicare has found a new method of denying covered compression therapy items without actually denying them. Medicare Summary Notices are now noting "Medicare will process your first claim only. In the future you must use a Medicare-Enrolled supplier and provide the supplier identification number on your claim." and "Medicare cannot process this claim as you were previously notified that you must use a supplier who has a Medicare supplier identification number." If you plan to appeal the denial of compression bandage systems, garments or devices, it would be prudent for you to purchase them from an enrolled supplier. Since these items will be denied, the supplier will ask you to pay up front and sign an Advance Beneficiary Notice of Nonpayment (ABN) form signifying that you understand that Medicare may not reimburse you for the purchase. This gets the supplier off the hook when it is denied. The supplier is then obliged BY LAW to file the initial claim for you. It seems that Medicare will process one claim and one claim only from a beneficiary who has purchased a medical item from a non-enrolled supplier or from the manufacturer. In this case the beneficiary files a Patient's Request for Medicare Payment and the claim is processed by hand, instead of by computer, and takes a longer time to process. The following is a recent CMS clarification on participating and non-participating suppliers: "**Updated February 10, 2009- Clarification from January's DMEPOS Special Open Door Forum. Participating Provider/Supplier and Accreditation requirements Medicare enrolled participating providers and suppliers must always accept assignment. Assignment is an agreement between beneficiaries, their providers/suppliers, and Medicare where the beneficiary authorizes the provider/supplier to request direct Part B payment from Medicare for health care services, equipment, and supplies. When the provider/supplier agrees to (or is required by law to) accept assignment from Medicare, then the provider/supplier is prohibited from attempting to collect more than the applicable Medicare deductible and coinsurance amounts from the beneficiary, the beneficiary's other insurance, or anyone else. Providers/suppliers that enter into a Medicare Participating Physician or Supplier Agreement (OMB No.0938-0373) agree to accept the Medicare-approved amounts as payment in full for all Part B services and supplies. A beneficiary should only pay the 20% co-pay (and any remaining Part B deductible) when they receive their equipment or supplies or when the equipment is repaired. A Medicare enrolled non-participating provider/supplier, can choose which services to accept assignment for (unless mandatory assignment applies to the service; e.g., for drugs or biologicals, ambulance services, etc.). Therefore, the provider's/supplier's charges for DME supplies may be higher than the Medicare approved amount and the beneficiary has to pay the entire charge for the Part B services and supplies at the time of service. (NOTE: Medicare's limiting charge does not apply to DME supplies.) In either case, participating and non-participating, Medicare providers/suppliers must bill Medicare on behalf of the beneficiary and must be accredited by September 30, 2009 in order to retain their Medicare Part B billing privileges." The above material is the undersigned's interpretation of Medicare policy and procedures. It is my opinion only and is not authorized or approved by Medicare. This information is not to be used for medical or legal purposes, and is offered only as an aid in navigating the Medicare labyrinth. Source: Bob Weiss, Lymphedema Patient Advocate, Medicare.gov website. ======================================================= Letter to write for lymphedema day Senator _________________ [Address] [City, State, Zip] Dear Senator _____________________: I am a [lymphedema patient, breast cancer survivor, advocate and volunteer at the Carol Baldwin Breast Care Center]. I would like to call your attention to Virginia House Joint Resolution No. 524 (please see enclosed copy). This resolution proclaims each March 6th as Lymphedema D- Day in the State of Virginia. It would be a great step forward for this "orphan disease" if each state and the United States government would proclaim March 6th of each year as Lymphedema D-Day. As one of your constituents, I cannot stress enough the impact that this disease has on patients. For further information, you may contact the National Lymphedema Network (800-541-3259 or online at www.lymphnet.org). If I can be of any assistance in promoting this resolution, please do not hesitate to contact me. I thank you, in advance, for your support. Very truly yours, [Your name] ===================================================== There are several bills before the NY State Assembly and the NY State Senate regarding lymphedema that would be of interest and concern to you. What the bill(s) say in part are: "To create awareness of lymphedema through education and to promote and support the availability of quality medical treatment for all individuals at risk or affected by lymphedema". The bills that are to be voted on are A5320 (NY Assembly bill), S629 (NY Senate bill) and A5321 (NY State Assembly bill), S2585 (NY State Senate bill. To read all of the information on these important bills regarding lymphedema go to www.ny.gov which is the home page for the State of New York. On the right side you will find a section called LEGISLATIVE and under that heading you will find New York State Assembly and New York State Senate. By clicking onto those headings you will find on the left side Bills and Laws where you can enter the bill number to read what it entails, they are quite detailed. The bills in both the Assembly and the Senate are cross-referenced so you can look at both in as much detail as you like by checking boxes of what information you want to review. Also on the left side you will find Assembly and Senate and you can click onto those and it will give you a list of your representatives for your area and you can write to them if you like and let them know how you feel about the bill(s) that are to be voted on. You can search by your zip code to find the appropriate members for your area and their email addresses to write to them if you want. If you are wanting to write and give your support, non-support or comments and feelings on the particular bill the Assembly Members and Senate Members will be better equipped to vote on that bill. It would also be good if you wanted to email Senator Thomas K. Duane at duane@senate.state.ny. us who chairs the health committee and let him know how you feel on these particular bills. Of course, it is your decision if you want to email these people to let them know how you feel about these important bills concerning lymphedema legislation for the State of New York. You MUST be a New York State resident to have an effect to comment on these bills that are now in process so this post is meant for NY residents only however anyone can look at them if they want to. This is meant to be informational only and is not an endorsement by Lymphland or it's management, these decisions are for NY State residents to make through their legislative process. |
| The following is a summary of a Wall Street Journal article on a subject of potential impact to all lymphedema patients on Medicare or Medicaid. One of the impacts of this upcoming competitive bidding program for durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) is that you wil have to obtain DMEPOS (compression bandages, garments, supplies, devices) from a small number of selected enrolled Suppliers. This might represent a major business impact for the specialized manufacturers and suppliers of lymphedema treatment items, and preclude any attempt for the patient/Beneficiary to obtain reimbursement for these items. I urge you all to call your Congressional legislators and ask them whether the small savings to Medicare are worth the major reduction in access to the items you use daily in the treatment of your lymphedema. Ask your DMEPOS Supplier about the impact of this program on the availability of your lymphedema treatment items. Bob Weiss Thursday, March 19, 2009 Medicare Wall Street Journal Examines Potential Effects of Medicare Competitive Bidding Program for Durable Medical Equipment The Wall Street Journal on Thursday examined "Medicare's second attempt at putting a competitive bidding program in place" for durable medical equipment and the potential effects on access to services for beneficiaries (Martinez, Wall Street Journal, 3/19). CMS attempted to implement the program last year, but a law enacted last summer delayed the initiative and required the agency to repeat the initial bidding process. In February, CMS announced plans to implement the program on April 19 (Kaiser Daily Health Policy Report, 2/23). According to the Journal, the program likely will reduce costs for Medicare and beneficiaries, who pay 20% of the cost of DME, but suppliers and some patient advocacy groups have raised concerns that "it also may mean new hassles for patients." In addition, some Medicare beneficiaries "worry about no longer being able to do business with providers they have come to rely on for lifesaving equipment," the Journal reports. Tyler Wilson -- president of American Association for Homecare, which represents DME suppliers -- said, "Competitive bidding is going to eliminate 90% of home care providers," adding, "The result is going to be lower quality and lower access to care for seniors and people with disabilities." In addition, AAH officials said that the program will reduce costs for Medicare by only a small amount. Expenditures for DME will account for less than 2% of the estimated $500 billion budget for Medicare this year, they said. Laurence Wilson, director of the chronic care policy group at CMS, said that the program will provide "value to Medicare and its beneficiaries, as well as taxpayers" and ensure that beneficiaries have access to needed DME. CMS officials also said that the program would reduce costs for Medicare by $1 billion annually (Wall Street Journal, 3/19). --------------------------- The following clarification refers to supplies used in conjunction with previously obtained DME, and how to document the medical necessity of the supplies. It is my opinion that this concept applies equally to supplies necessary for the use with prosthetic devices such as Reid Sleeves, Circaids, etc. These supplies, such as finger bandages, gauze sleeves, localized foam pads, etc are coverable, in my opinion, and should be claimed by Medicare patients. Make sure that you have a physician's prescription for use in the treatment of lymphedema. Bob Weiss Lymphedema Patient Advocate April 21, 2009 Supplies and Accessories Used With Beneficiary Owned Equipment April 2009 Clarification The DME MACs recently published an article addressing documentation requirements for supplies and accessories used with beneficiary owned equipment. This article only addressed equipment that was not paid for by Medicare FFS - i.e., only equipment that was paid by other insurance or by the beneficiary. For supplies and accessories used with that equipment, all of the following information must be submitted with the initial claim in Item 19 on the CMS-1500 claim form or in the NTE segment for electronic claims: * HCPCS code of base equipment; and, * A notation that this equipment is beneficiary-owned; and, * Date the patient obtained the equipment. Claims for supplies and accessories must include all three pieces of information listed above. Claims lacking any one of the above elements will be denied for missing information. Medicare requires that supplies and accessories only be provided for equipment that meets the existing coverage criteria for the base item. In addition, if the supply or accessory has additional, separate criteria, these must also be met. In the event of a documentation request from the contractor or a redetermination request, suppliers should provide information justifying the medical necessity for the base item and the supplies and/or accessories. Refer to the applicable Local Coverage Determination (s) and related Policy Article(s) for information on the relevant coverage, documentation and coding requirements. ------------------------------------------------------------------------------------------- July Quarterly Update for 2009 for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) MLN Matters Number: MM6511 HCPCS codes A6545, E0656, E0657 and L0113 were added to the HCPCS file effective January 1, 2009. The fee schedule amounts for these HCPCS codes are established as part of this update and are effective for claims with dates of service on or after January 1, 2009. These items were paid on a local fee schedule basis prior to implementation of the fee schedule amounts established in accordance with this update. Claims for the above codes with dates of service on or after January 1, 2009 that have already been processed will not be adjusted to reflect the newly established fees if they are resubmitted for adjustment. As part of this update CMS is adding the AW modifier to the fee schedule file for HCPCS code A6545 Gradient Compression Wrap, Non-Elastic, Below Knee, 30-50 MM HG, Each. Code A6545 is covered when it is used in the treatment of an open venous stasis ulcer. Currently, code A6545 is noncovered for the following conditions: Venous insufficiency without stasis ulcers, prevention of stasis ulcers, prevention of the reoccurrence of stasis ulcers that have healed, and treatment of lymphedema in the absence of ulcers. In these situations, since an ulcer is not present, the gradient compression wraps do not meet the definition of a surgical dressing. Suppliers are advised that when the non-elastic gradient compression wrap code A6545 is used in the treatment of an open venous stasis ulcer, it must be billed with the AW modifier. Claims for code A6545 that do not meet the covered indications should be billed without the AW modifier and as such, will be denied as non-covered. For Information on Lymphedema-related items: A6545 is the CircAid JuxtaFit E0656 is Segmental Pneumatic Appliance for the Trunk E0657 is Segmental Pneumatic Appliance for the Chest Note that the CircAid is not approved for the treatment of lymphedema in the absence of an open wound since it does not meet the coverage requirements of a “secondary surgical dressing” benefit. This is not to say that it could not be held to meet the coverage requirements of a different benefit category, such as “prosthetic devices”. Bob Weiss ------------------------------------------- please make the following correction. A6545 code covers the T3M only, not the Juxta-Fit as stated. T3M garment is specifically for Venous Disease not Lymphedema. If have any questions, please feel free to contact me. Thank you for your attention to this matter. Ingrid Adams Director of Sales CircAid Medical Products Phone: 800-247-2243 ext 233 Fax: 858-576-3555 ===================================== If you are associated with a wound clinic you may wish to comment on this upcoming policy change. Bob Weiss Healthcare Common Procedure Coding System (HCPCS) Coding Decision and Preliminary Medicare Payment Decision for Negative Pressure Wound Therapy (NPWT) Devices CMS' preliminary Healthcare Common Procedure Coding System (HCPCS) coding decision and preliminary Medicare Payment decision for negative pressure wound therapy (NPWT) devices is now published in the July 9, 2009 NPWT Public Meeting Agenda. This public meeting affords stakeholders an opportunity to provide input concerning the preliminary decision. The Medicare Improvements for Patients and Providers Act of 2008 required the Secretary to evaluate existing HCPCS codes for NPWT devices to ensure accurate reporting and billing for the items and services under such codes; use an existing process for the consideration of coding changes: and consider all relevant studies andinformation furnished through the process. CMS partnered with Agency of Healthcare Research and Quality (AHRQ) to commission a review of NPWT devices to ensure all relevant studies and information on NPWT were captured. ECRI Institute solicited information from stakeholders and searched literature in conducting this review. A draft report of their findings was published for comment in April 2009. After analysis of comments received, ECRI concluded that the available evidence does not support significant therapeutic distinction of a NPWT system or component of a system. The report informed CMS' HCPCS workgroup's decision. The final report will be publicly available no later than June 10, 2009 on AHRQ's homepage for the Technology Assessment Program at http://www.ahrq. gov/clinic/ techix.htm. ============================ The Durable Medical Equipment Medicare Administrative Contractor Jurisdiction A (DME MAC A) NHIC, Corp. has announced a change in Medicare billing policy in a Surgical Dressing LCD Article Surgical Dressings Policy Article Revision Effective Date: 01/01/2009 (September Publication) CODING GUIDELINES: Added: A6545 to list of codes requiring the AW modifier. Added: A6545 to list of codes requiring the RT and/or LT modifier(s). Revised: RT/LT modifier instructions. The change may be found in Article for Surgical Dressings - Policy Article - Effective January 2009 (September 2009 Publication) (A23664) Abstracted information of possible interest to the lymphedema/wound care community is as follows: A6545 GRADIENT COMPRESSION WRAP, NON-ELASTIC, BELOW KNEE, 30-50 MM HG, EACH GRADIENT COMPRESSION STOCKINGS/WRAPS (A6531, A6532, A6545): A gradient compression stocking described by codes A6531 or A6532 or a non-elastic gradient compression wrap described by code A6545 is covered when it is used in the treatment of an open venous stasis ulcer. Codes A6531, A6532, and A6545 are noncovered for the following conditions: venous insufficiency without stasis ulcers, prevention of stasis ulcers, prevention of the reoccurrence of stasis ulcers that have healed, treatment of lymphedema in the absence of ulcers. In these situations, since there is no ulcer, the stockings/wraps do not meet the definition of a surgical dressing. Gradient compression stockings described by codes A6530, A6533-A6544, A6549 and surgical stockings described by codes A4490-A4510 are noncovered for all indications because they do not meet the definition of a surgical dressing. A nonelastic binder for an extremity (A4465) is noncovered for all indications because it does not meet the definition of a surgical dressing. The only products that may be billed with code A6545 (non-elastic compression wrap) are those which have received a written Coding Verification Review from the Pricing, Data Analysis, and Coding (PDAC) contractor and that are posted in the Product Classification List on the PDAC web site. When tape codes A4450 and A4452 are used with surgical dressings, they must be billed with the AW modifier (in addition to the appropriate A1-A9 modifier). When gradient compression stocking codes A6531 and A6532 or the gradient compression wrap code A6545 are used for an open venous stasis ulcer, they must be billed with the AW modifier (but not an A1-A9 modifier). For this policy, codes A4450, A4452, A6531, and A6532, and A6545 are the only codes for which the AW modifier may be used. The RT and/or LT modifiers must be used with codes A6531, A6532, and A6545 for gradient compression stockings and wraps. When the same code for bilateral items (left and right) is billed on the same date of service, bill both items on the same claim line using RTLT modifiers and 2 units of service. Claims billed without modifiers RT and/or LT will be rejected as incorrect coding. GRADIENT COMPRESSION WRAP (A6545): Coverage of a non-elastic gradient compression wrap (A6545) is limited to one per 6 months per leg. Quantities exceeding this amount will be denied as not medically necessary. Refer to Policy Article for statement concerning noncoverage if the ulcer has healed. Revision History Explanation Revision Effective Date: 01/01/2009 (September Publication) CODING GUIDELINES: Added: A6545 to list of codes requiring the AW modifier. Added: A6545 to list of codes requiring the RT and/or LT modifier(s). Revised: RT/LT modifier instructions. Revision Effective Date: 01/01/2009 NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES: Clarified: Allowance for HCPCS codes which use the term “kit”. Added: Coverage statements for compression wraps (A6545). Added: Noncoverage statement for surgical stockings (A4490-A4510). CODING GUIDELINES: Added: Requirement for PDAC Coding Verification Review for non-elastic compression wraps (A6545). Revised: Changed SADMERC to PDAC. ------ I found another article you may be interested in reading that came from Center for Medicare and Medicaid Services...."Medicare's New Requirements For Durable Medical Equipment, Prothestics, Orthotics, And Supplies". This may be accessed at the following: http://www.medicare.gov/publications/pubs/pdf/11437.pdf -------------------------- I came across an article from the National Cancer Institute that you might be interested in reading...." Weight Lifting Does Not Exacerbate And May Improve Lymphedema Symptoms After Breast Cancer". You can access the article at: http://www.cancer.gov.clinicaltrials/results/lymphedema0909 ================================== The above Local Coverage Determination LCD) and its accompanying coverage article represent the Medicare basis for denial of compression bandages, garments and sevices. In this writer's humble opinion, validated by several Administrative Law Judges, this LCD applies only to the coverage criteria for the Medicare benefit category of SURGICAL DRESSINGS, which by statute and policy, covers only materials used in the treatment of open wounds, incisions, venous ulcers, etc. They derive ultimately from the Social Security Act section 1861(s)(5), surgical dressings. As a matter of law, the criteria for coverage under one benefit category cannot be used to deny coverage of an item which falls into the definition of a different benefit category. When used in the compression treatment of lymphedema these materials (compression bandages, garments and sevices) meet the definition of PROSTHETIC DEVICES, and are therefore covered by Medicare. They cannot be denied by invoking the coverage criteria for surgical dressings as documented in the "LCD for Surgical Dressings (L11471)" and its "Article for Surgical Dressings Policy Article A23664)". Robert Weiss, MS Lymphedema Patient Advocate National Lymphedema Network LymphActivist@aol.com ----- Plaintiffs win suit to keep their Social Security benefits even if they reject Medicare Constitutional attorney Kent Masterson Brown has won an important legal victory on behalf of three plaintiffs — former Congressman Dick Armey, Brian Hall and John Kraus — who sued to keep their Social Security benefits after they withdrew from Medicare Part A, preferring to keep their private healthcare coverage. The Department of Health and Human Services had sought to dismiss the suit, arguing that the plaintiffs had not exhausted their administrative remedies. But U.S. District Judge Rosemary Collyer, noting that one plaintiff has waited three years for an administrative hearing without action, ruled that the plaintiffs had standing to contest their claim on the merits of the case. On October 5, 2009, the Wall Street Journal published an editorial regarding the judge’s decision, saying, “This (case) could be a big deal”. The plaintiffs argued that as they had paid a lifetime of taxes into Social Security, they should not be denied benefits simply because they are willing to pay for their own medical care. In 1993, under the Clinton administration, Social Security’s Program Operations Manual System (POMS) was changed to state that seniors who withdraw from Medicare A also surrender their Social Security benefits. You can’t have one without the other. But POMS is not in the statute or regulations that govern Medicare. According to the Wall Street Journal, the response of the Department of HHS speaks volumes about the contradiction between the Obama administration’s principles and its rhetoric: “President Obama says his plan for a ‘public option’ wouldn't be coercive, saying that ‘If you like your health-care plan, you keep your health-care plan. Nobody is going to force you to leave your health-care plan.’ But here is a case where federal bureaucrats are using their power to force Medicare on seniors. Let's hope the courts restore a genuine right to choose.” Freedom of healthcare choice is a big deal. Should Medicare become insolvent, as it is widely expected to do, seniors may not be able to opt out in order to preserve their health insurance. Coercion in your choice of healthcare is a key part of the current healthcare legislation. October 20, 2009 Plaintiffs win suit to keep their Social Security benefits even if they reject Medicare Constitutional attorney Kent Masterson Brown has won an important legal victory on behalf of three plaintiffs — former Congressman Dick Armey, Brian Hall and John Kraus — who sued to keep their Social Security benefits after they withdrew from Medicare Part A, preferring to keep their private healthcare coverage. The Department of Health and Human Services had sought to dismiss the suit, arguing that the plaintiffs had not exhausted their administrative remedies. But U.S. District Judge Rosemary Collyer, noting that one plaintiff has waited three years for an administrative hearing without action, ruled that the plaintiffs had standing to contest their claim on the merits of the case. On October 5, 2009, the Wall Street Journal published an editorial regarding the judge’s decision, saying, “This (case) could be a big deal”. The plaintiffs argued that as they had paid a lifetime of taxes into Social Security, they should not be denied benefits simply because they are willing to pay for their own medical care. In 1993, under the Clinton administration, Social Security’s Program Operations Manual System (POMS) was changed to state that seniors who withdraw from Medicare A also surrender their Social Security benefits. You can’t have one without the other. But POMS is not in the statute or regulations that govern Medicare. According to the Wall Street Journal, the response of the Department of HHS speaks volumes about the contradiction between the Obama administration’s principles and its rhetoric: “President Obama says his plan for a ‘public option’ wouldn't be coercive, saying that ‘If you like your health-care plan, you keep your health-care plan. Nobody is going to force you to leave your health-care plan.’ But here is a case where federal bureaucrats are using their power to force Medicare on seniors. Let's hope the courts restore a genuine right to choose.” Freedom of healthcare choice is a big deal. Should Medicare become insolvent, as it is widely expected to do, seniors may not be able to opt out in order to preserve their health insurance. Coercion in your choice of healthcare is a key part of the current healthcare legislation. October 20, 2009 Plaintiffs win suit to keep their Social Security benefits even if they reject Medicare Constitutional attorney Kent Masterson Brown has won an important legal victory on behalf of three plaintiffs — former Congressman Dick Armey, Brian Hall and John Kraus — who sued to keep their Social Security benefits after they withdrew from Medicare Part A, preferring to keep their private healthcare coverage. The Department of Health and Human Services had sought to dismiss the suit, arguing that the plaintiffs had not exhausted their administrative remedies. But U.S. District Judge Rosemary Collyer, noting that one plaintiff has waited three years for an administrative hearing without action, ruled that the plaintiffs had standing to contest their claim on the merits of the case. On October 5, 2009, the Wall Street Journal published an editorial regarding the judge’s decision, saying, “This (case) could be a big deal”. The plaintiffs argued that as they had paid a lifetime of taxes into Social Security, they should not be denied benefits simply because they are willing to pay for their own medical care. In 1993, under the Clinton administration, Social Security’s Program Operations Manual System (POMS) was changed to state that seniors who withdraw from Medicare A also surrender their Social Security benefits. You can’t have one without the other. But POMS is not in the statute or regulations that govern Medicare. According to the Wall Street Journal, the response of the Department of HHS speaks volumes about the contradiction between the Obama administration’s principles and its rhetoric: “President Obama says his plan for a ‘public option’ wouldn't be coercive, saying that ‘If you like your health-care plan, you keep your health-care plan. Nobody is going to force you to leave your health-care plan.’ But here is a case where federal bureaucrats are using their power to force Medicare on seniors. Let's hope the courts restore a genuine right to choose.” Freedom of healthcare choice is a big deal. Should Medicare become insolvent, as it is widely expected to do, seniors may not be able to opt out in order to preserve their health insurance. Coercion in your choice of healthcare is a key part of the current healthcare legislation. October 20, 2009 http://www.healthfreedom.net/index.php?option=com_content&task=view&id=922&Itemid=1 ------ The amount in Controversy minimums to be able to bring an appeal to a Medicare Administrative Law Judge (ALJ) hearing has been raised from $120.00 in 2009 to $130.00 in 2010. What that means is that a disputed item (compression bandage kit or compression garment) must cost more than $162.50 before you can have an ALJ hearing since the disputed amount, which is the purchase price minus the 20% co-pay, must be more than $130.00). Otherwise don't bother filing a claim or an appeal. You need two garments anyway so that one can be worn while the other dries. Bob Weiss Reference [Federal Register: September 25, 2009 (Volume 74, Number 185)] [Notices] [Page 48976-48977] DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [CMS-4141-N] Medicare Program; Medicare Appeals; Adjustment to the Amount in Controversy Threshold Amounts for Calendar Year 2010 AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ---- How can a Medicare beneficiary find out if their supplier does not meet the new requirements? Medicare beneficiaries should ask their suppliers if they meet the new Medicare requirements so they can continue to get their suppliers covered by Medicare and to avoid any interruption in their services. What should a Medicare beneficiary do if their supplier does not meet the new requirements? If a beneficiary's supplier isn't going to meet the new requirements, they will have to look for another Medicare-approved supplier in order for Medicare to pay for their equipment and supplies. How does a beneficiary find a new Medicare supplier? Beneficiaries should ask their current supplier if they are working with another supplier who can help the beneficiary. If the beneficiary's current supplier can't help, the beneficiary should call 1-800- MEDICARE (1-800-633-4227) and a customer service representative can help them find a new supplier. TTY users should call 1-877-486-2048. Or, visit www.medicare.gov and select "Find Suppliers of Medical Equipment in Your Area." In order to ensure Medicare payment, beneficiaries should always ask any new supplier they contact if they are still approved by Medicare to provide covered medical equipment and supplies. What if a beneficiary doesn't want to change suppliers? Starting October 1, 2009, all suppliers must meet the new Medicare requirements in order to be paid by Medicare. If a supplier hasn't met these requirements and a beneficiary continues to get supplies from the supplier, the beneficiary may have to pay the full cost for the supplies. What should a beneficiary do if they have oxygen and their current supplier told them that they are removing their equipment after October 1, 2009? A beneficiary should call 1-800-MEDICARE (1-800-633-4227) and a customer service representative can help them find a new supplier. TTY users should call 1-877-486-2048. What will happen with equipment in a beneficiary's home if they have to change suppliers? A beneficiary's current supplier should make arrangements to remove the equipment after the beneficiary has received replacement equipment from their new supplier. What if my new supplier does not provide a beneficiary with the supplies their doctor originally ordered? The new supplier has an obligation to provide a beneficiary with the supplies that their physician orders for them. If a beneficiary has any concerns, they should contact their doctor to discuss them. What if a beneficiary's existing supplier is the only one in their town and is not Medicare approved? A beneficiary's existing supplier may choose not to participate. Beneficiaries should call 1-800- MEDICARE (1-800-633-4227) and a customer service representative can help them find a new supplier in their area. TTY users should call 1-877-486-2048. What can a beneficiary do if they have a complaint about their DME supplier? CMS can assist a beneficiary who has a complaint about their DME supplier. Beneficiaries should call 1-800-MEDICARE (1-800-633-4227) and give the customer service representative the name and address of their supplier and the nature of their complaint. Someone from CMS and/or the supplier will get back to the beneficiary as soon as possible. Will a beneficiary's prescription drugs be affected by the new requirements? A beneficiary's prescription drugs are not affected by the new requirements, only the medical supplies that they are receiving. Why can't a beneficiary continue to go to their pharmacy to get their diabetic supplies? If a beneficiary's pharmacy hasn't met Medicare's new requirements, they won't be able be able to provide the beneficiary's diabetic supplies after October 1, 2009. To find a pharmacy that can provide diabetic supplies or a mail order supplier, a beneficiary should visit www.medicare.gov and select "Find Suppliers of Medicare Equipment in Your Area." Or, call 1-800-MEDICARE (1-800-633- 4227). TTY users should call 1-877-486-2048. Must a non-accredited supplier use an Advance Beneficiary Notice (ABN) before selling DMEPOS items to a beneficiary? Non-accredited suppliers should use an Advance Beneficiary Notice (ABN) before providing a Medicare beneficiary with an item or service to alert the beneficiary to the fact that the supplier is non- accredited and unable to bill Medicare for the item – so the beneficiary knows they will have to pay the full cost for the item or service. The only exception to this rule is when a non-accredited supplier has posted clearly visible signs (undisputed by the beneficiary) at the supplier's place of business that informs beneficiaries that it is not accredited by Medicare and cannot bill Medicare, so the beneficiary knows they must pay for the item or service. Is a beneficiary protected if they purchase a supply from a non-accredited supplier? There are retail outlets and pharmacies that furnish DMEPOS items to cash and carry customers which do not meet the new Medicare requirements. Therefore beneficiaries should always ask if the supplier meets the new Medicare requirements to make sure Medicare will pay for their supplies. Medicare "may" reimburse a beneficiary for a one-time only supply and give notice to the beneficiary that any future bills will not be reimbursed. The supplier locator tool on www.medicare.gov is available to beneficiaries to locate enrolled DMEPOS suppliers that service their area. Can a non-accredited pharmacy that provides DME supplies to a dual eligible beneficiary be reimbursed by Medicaid? As long as the pharmacy is a Medicaid provider, the pharmacy may be reimbursed by Medicaid for a Medicaid-covered item. Will a beneficiary's Medicare premium increase because the suppliers now need to be accredited/obtain a surety bond? A beneficiary's Medicare premium is not affected by these new Medicare requirements. ----- NHIC, Corp., Medicare DME MAC Jurisdiction A has posted the results of a review of claims for a lymphedema pump. The review revealed that over half of the claims for lymphedema pumps have been rejected or down-graded. An analysis of the reasons for rejection can help future requests for these devices. The results point up the importance of having a well-written Certificate of Medical Necessity (CMN) DME MAC Form 04.04B /CMS Form 846 Pneumatic Compression Devices signed by the patient's physician. The CMN must show that the use of a multichambered sequential pressure pneumatic compressor with calibrated gradient pressure is medically necessary for the treatment of the patient's lymphedema, that other "more conservative" protocols such as elevation, compression and exercise have been tried and have not been successful, that there is a medical reason for this patient to have a pump because of difficulty in performing CDT at home. Note that 14% of the claims were denied on the basis that "equipment is the same or similar to equipment already in use" even though Medicare frequently requires a failed trial of non-segmented pumps before a more appropriate model is approved [Ref. LCD L11503]. Physicians must be meticulous and complete in writing their prescription, including the diagnostic code for lymphedema, the physician's name address and NPI, and as full a description of the type of pump that is medically indicated, including the designation of the kinds of garments required (e.g. full sleeve or legging, upper or lower body segment, etc.) Bob Weiss Results of Widespread Prepayment Review of Claims for HCPCS Code E0652 (Pneumatic Compressor, Segmental Home Model with Calibrated Gradient Pressure) Posted October 30, 2009 The DME MAC A Medical Review Department concluded a widespread review of HCPCS code E0652 from June 2009 through September 2009. The results of the quarterly review of the claims from June 1, 2009 through September 30, 2009 identified eight hundred sixty-five (865) claims of which two hundred sixty-three (263) were denied. This resulted in an overall Charge Denial Rate of 54.00%. The following are the top five (5) reasons for denial: o The equipment is considered not reasonable and necessary (69 claims) o The prescription is incomplete (46 claims) o Duplicate claims (43 claims) o Equipment is same or similar to equipment already in use (38 claims) o Claim not payable under Jurisdiction A (e.g., claim submitted to incorrect contractor) (16 claims) The other reasons for denial are as follows: (51 claims) o Patient eligibility (e.g., patient cannot be identified as Medicare insured; beneficiary not covered by Medicare; or beneficiary covered by another plan or HMO, etc.) o Date of death precedes date of service o Missing or incomplete supplier information o Claim contains incomplete or invalid information (e.g., missing or incomplete diagnosis or condition) o No response to medical records request o The equipment was provided while the patient is in the nursing home o Lifetime benefit maximum for equipment has been reached The Local Coverage Determination (LCD) for Pneumatic Compression Devices (L11503) states in part: Pneumatic Compression Devices are only covered for the treatment of lymphedema or for the treatment of chronic venous insufficiency with venous stasis ulcers, prescribed by a physician and determination by the physician of the medical necessity which must include the following: o The patient's diagnosis and prognosis; o Symptoms and objective findings, including measurements which establish the severity of the condition; o The reason the device is required, including the treatments which have been tried and failed; and o The clinical response to an initial treatment with the device. The clinical response includes the change in pre-treatment measurements, ability to tolerate the treatment session and parameters and ability of the patient (or caregivers) to apply the device for continued use in the home. The medical documentation submitted for five hundred thirty-four (534) claims supported the medical necessity for a lower level item, thus the services were down-coded to the least costly alternative. The Pneumatic Compression Devices (L11503) LCD states: “When a segmented device with manual control of the pressure in each chamber (E0652) is ordered and provided, payment will be based on the allowance for the least costly medically appropriate alternative, E0651, unless there is clear documentation of medical necessity in the individual case. Full payment for code E0652 will be made only when there is documentation that the individual has unique characteristics that prevent satisfactory pneumatic compression treatment using a non-segmented device (E0650) with a segmented appliance/sleeve (E0671 - E0673) or a segmented device without manual control of the pressure chamber (E0651).” For any item to be covered by Medicare, it must: o Be eligible for a defined Medicare benefit category; o Be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member; and o Meet all other applicable Medicare statutory and regulatory requirements. Suppliers are reminded that documentation must be made available to the DME MAC upon request. Reference the following under the Documentation Requirements section in the Pneumatic Compression Devices (L11503) LCD, which states in part: “Section 1833 (e) of the Social Security Act precludes payment to any provider of services unless “there has been furnished such information as may be necessary in order to determine the amounts due such provider” (42 U.S.C. section 13951 (e)). It is expected that the patient's medical records will reflect the need for the care provided. The patient's medical records include the physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available upon request.” Reference the following publications for documentation requirements for HCPCS code E0650 - E0652, the DME MAC A Supplier Manual and the Pneumatic Compression Devices (L11503) LCD. These are available on the DME MAC A Web site at: http://www.medicarenhic.com/dme/index.shtml _____________________________________________________________________________ _____________________________________________________________________________ _____________ Document Name: DME Web site Article Template Document Number: TMP-EDO-0049 Release Date: 11/28/2007 Version: 1.0 The master copy of this document is stored in the NHIC ISO Documentation Repository. Any other copy, either electronic or paper, is an uncontrolled copy and must be deleted or destroyed when it has served its purpose. ------------------ NHIC, Corp., Medicare DME MAC Jurisdiction A has posted the results of a review of claims for a lymphedema pump. The review revealed that over half of the claims for lymphedema pumps have been rejected or down-graded. An analysis of the reasons for rejection can help future requests for these devices. The results point up the importance of having a well-written Certificate of Medical Necessity (CMN) DME MAC Form 04.04B /CMS Form 846 Pneumatic Compression Devices signed by the patient's physician. The CMN must show that the use of a multichambered sequential pressure pneumatic compressor with calibrated gradient pressure is medically necessary for the treatment of the patient's lymphedema, that other "more conservative" protocols such as elevation, compression and exercise have been tried and have not been successful, that there is a medical reason for this patient to have a pump because of difficulty in performing CDT at home. Note that 14% of the claims were denied on the basis that "equipment is the same or similar to equipment already in use" even though Medicare frequently requires a failed trial of non-segmented pumps before a more appropriate model is approved [Ref. LCD L11503]. Physicians must be meticulous and complete in writing their prescription, including the diagnostic code for lymphedema, the physician's name address and NPI, and as full a description of the type of pump that is medically indicated, including the designation of the kinds of garments required (e.g. full sleeve or legging, upper or lower body segment, etc.) Bob Weiss Results of Widespread Prepayment Review of Claims for HCPCS Code E0652 (Pneumatic Compressor, Segmental Home Model with Calibrated Gradient Pressure) Posted October 30, 2009 The DME MAC A Medical Review Department concluded a widespread review of HCPCS code E0652 from June 2009 through September 2009. The results of the quarterly review of the claims from June 1, 2009 through September 30, 2009 identified eight hundred sixty-five (865) claims of which two hundred sixty-three (263) were denied. This resulted in an overall Charge Denial Rate of 54.00%. The following are the top five (5) reasons for denial: o The equipment is considered not reasonable and necessary (69 claims) o The prescription is incomplete (46 claims) o Duplicate claims (43 claims) o Equipment is same or similar to equipment already in use (38 claims) o Claim not payable under Jurisdiction A (e.g., claim submitted to incorrect contractor) (16 claims) The other reasons for denial are as follows: (51 claims) o Patient eligibility (e.g., patient cannot be identified as Medicare insured; beneficiary not covered by Medicare; or beneficiary covered by another plan or HMO, etc.) o Date of death precedes date of service o Missing or incomplete supplier information o Claim contains incomplete or invalid information (e.g., missing or incomplete diagnosis or condition) o No response to medical records request o The equipment was provided while the patient is in the nursing home o Lifetime benefit maximum for equipment has been reached The Local Coverage Determination (LCD) for Pneumatic Compression Devices (L11503) states in part: Pneumatic Compression Devices are only covered for the treatment of lymphedema or for the treatment of chronic venous insufficiency with venous stasis ulcers, prescribed by a physician and determination by the physician of the medical necessity which must include the following: o The patient's diagnosis and prognosis; o Symptoms and objective findings, including measurements which establish the severity of the condition; o The reason the device is required, including the treatments which have been tried and failed; and o The clinical response to an initial treatment with the device. The clinical response includes the change in pre-treatment measurements, ability to tolerate the treatment session and parameters and ability of the patient (or caregivers) to apply the device for continued use in the home. The medical documentation submitted for five hundred thirty-four (534) claims supported the medical necessity for a lower level item, thus the services were down-coded to the least costly alternative. The Pneumatic Compression Devices (L11503) LCD states: “When a segmented device with manual control of the pressure in each chamber (E0652) is ordered and provided, payment will be based on the allowance for the least costly medically appropriate alternative, E0651, unless there is clear documentation of medical necessity in the individual case. Full payment for code E0652 will be made only when there is documentation that the individual has unique characteristics that prevent satisfactory pneumatic compression treatment using a non-segmented device (E0650) with a segmented appliance/sleeve (E0671 - E0673) or a segmented device without manual control of the pressure chamber (E0651).” For any item to be covered by Medicare, it must: o Be eligible for a defined Medicare benefit category; o Be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member; and o Meet all other applicable Medicare statutory and regulatory requirements. Suppliers are reminded that documentation must be made available to the DME MAC upon request. Reference the following under the Documentation Requirements section in the Pneumatic Compression Devices (L11503) LCD, which states in part: “Section 1833 (e) of the Social Security Act precludes payment to any provider of services unless “there has been furnished such information as may be necessary in order to determine the amounts due such provider” (42 U.S.C. section 13951 (e)). It is expected that the patient's medical records will reflect the need for the care provided. The patient's medical records include the physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available upon request.” Reference the following publications for documentation requirements for HCPCS code E0650 - E0652, the DME MAC A Supplier Manual and the Pneumatic Compression Devices (L11503) LCD. These are available on the DME MAC A Web site at: http://www.medicare nhic.com/ dme/index. shtml ____________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ __ Document Name: DME Web site Article Template Document Number: TMP-EDO-0049 Release Date: 11/28/2007 Version: 1.0 The master copy of this document is stored in the NHIC ISO Documentation Repository. ---- Worth reading! http://www.aarpmagazine.org/money/health_claim_game.html?print=yes# If you need help with your lymphedema claim please contact me. Bob Weiss LymphActivist@aol.com ------ Thu, 12 Nov 2009 13:49:00 -0600 Date: 11/12/2009 Subject: AHRQ Draft TA for review Content: and Treatment of Secondary Lymphedema The Agency for Healthcare Research and Quality's (AHRQ) Technology Assessment Program will be posting a draft technology assessment for review on November 18, 2009. This draft is entitled "Diagnosis and Treatment of Secondary Lymphedema." If you are interested in reviewing this document, please visit: http://www.ahrq. gov/clinic/ ta/tareview. htm. The document will be available for review from 9:00 AM on November 18, 2009 to 5:00 PM December 8, 2009. Call for Public Review -------------------------------------------------------------------------------- The Agency for Healthcare Research and Quality's (AHRQ) Technology Assessment (TA) Program develops systematic reviews, health technology assessments, and other reports at the request of the Centers for Medicare & Medicaid Services (CMS) Coverage and Analysis Group. These reports are funded by an Interagency Agreement from CMS to AHRQ and used to inform national coverage policies, discussion at public Medicare Evidence Development and Coverage Advisory Committee (MedCAC) meetings, and/or for other policy considerations. To get complete public review, the AHRQ TA Program will post draft reports on the AHRQ TA Web site. To meet the timelines for Medicare coverage decisions mandated by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, draft technology assessment reports will be available for public review for a limited time. A notice will be sent out on the CMS Medicare Coverage and AHRQ Effective Health Care E-mail distribution lists 1 week before the posting of draft reports. Each report will be available for public review on this Web site for a total of 2 weeks. AHRQ's TA Program supports and is committed to the transparency of its review process. Therefore, starting March 18, 2009, invited peer review comments and public review comments will be publicly posted on the TA Program Web site at http://www.ahrq. gov/clinic/ techix.htm within 3 months after the associated final report is posted on this Web site. The report authors' responses to the comments (the "disposition of comments") will be posted on the same Web page as the associated comments. Review Steps When a draft Technology Assessment report is available for review, you may review the draft report by completing the associated review form and then selecting "Submit" on the form. Note: Comments received after the review period will not be accepted. Available Soon Diagnosis and Treatment of Secondary Lymphedema. Available for review November 18 to December 8, 2009 Questions Please contact ahrqtap@ahrq. hhs.gov if you have any questions. This is an opportunity (maybe the last for another 10 years) to use your knowledge and experience to help shape Medicare lymphedema coverage policy. -- Robert Weiss, MS Lymphedema Patient Advocate National Lymphedema Network ---- If you are one of the millions of people who are struggling to pay medical bills, you should be aware of the steps you can take to reduce or manage your debt. If you owe money to a hospital or medical provider, do not ignore your bills. It will be harder to straighten out billing mistakes or get financial assistance if you wait. Making timely payments will also help you avoid further debt, damage to your credit score, lawsuits, and “garnishment” (deductions from your wages or bank account). But, if you cannot pay anything right now, you may be able to get financial assistance, and you should see if your provider will agree to wait before charging interest or sending your debt to a collection agency. This consumer guide covers steps for paying your medical bills, understanding your rights, and other information you need to know if you are struggling with medical debt. The guide also includes links to other useful resources. http://www.familiesusa.org/resources/resources-for-consumers/coping-with-medical-debt.html Robert Weiss, M.S. Lymphedema Treatment Advocate National Lymphedema Network ---- CMS MEDCAC Meeting on Lymphedema (Impressions of LymphActivist) 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 NLN took a leading 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. NLN Medical Advisory Committee (MAC) members sat on the panel, gave an invited speech, and gave scheduled and unscheduled testimony. The open meeting featured a presentation of the Technology Assessment HHS/AHRQ commissioned from McMaster University Evidence-based Practice Center, Hamilton ONT 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. The NLN was well represented at this meeting and provided valuable inputs to CMS. The Expert Panel comprised 10 voting members chosen from the eighty-eight permanent MEDCAC members plus a Patient Advocate, an Industry Representative and three guest panel members who were non-voting. The goal of the meeting was to present the best evidence on the measurement and diagnostic and treatment methods for secondary lymphedema, to question and hear testimony of the community of experts and to vote on the adequacy of the evidence to support use (coverage?) of each method. 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. It was the suggestion of one of the NLN MAC Physicians that the treatment of multimodal, and that it made little sense to vote on individual modalities when the current treatment standard CDT is a combination of modalities. CDT was added to the list to be voted on. CDT plus sequential pneumatic compression was also added since one of the high-level trials considered it. An open vote by the expert panel indicated that the final assessment would be that there is at least intermediate confidence that CDT alone, CDT with adjuvant pneumatic compression, compression bandages and compression garments, and pneumatic compression devices produce clinically meaningful improved health outcomes for lymphedema patients. A vote on measurement methods was that no imaging technique had adequate evidence to identify and stratify severity of secondary lymphedema, that only physical exam, patient-reported symptomatology, water displacement and circumferential measurement had adequate evidence to determine limb volume, and that only patient- reported symptomatology had adequate evidence to identify sub-clinical lymphedema. Another conclusion was that there is little confidence that our knowledge and measurement tools allow us to classify secondary lymphedema into stages of severity that will be useful to guide choice of therapy or predict response to therapy. We fared much better with respect to the question of whether there was expert confidence that improvement in a number of measures would be associated with improvement of patients' health. Limb circumference, limb volume, symptom assessment, limb function, activities of daily living, frequency of skin breakdown, frequency of skin infection, quality of life assessment and social integration were all felt to have medium to high confidence based on existing evidence. The MEDCAC Lymphedema Panel will be publishing their final assessment, with all supporting evidence and comments submitted by the public, on the CMS MEDCAC web site within 90 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. Since most of the clinical trials which went into these determinations were trials involving upper limb breast cancer-related lymphedema, the last question asked whether there was confidence that the diagnostic strategies and treatment methods were generalizable to Medicare beneficiaries with secondary lymphedema. There was intermediate confidence that they were generalizable. A key point to be made here is that this entire meeting was focused on the evidence resulting from randomized clinical trials, and had no way of considering clinical evidence, anatomical and biological knowledge, observational evidence, expert clinician opinion, consensus-based guidelines, case studies, non-randomized experiments, etc. The “rules of evidence” do not consider this vast body of knowledge and experience that form the basis of lymphedema treatment. This evidence was brought in by the meeting attendees. So what's the bottom line, you ask? I am greatly encouraged. Medicare has finally, after ten years, started the process of looking into the coverage of lymphedema diagnosis and treatment. The process of defining coverage change is a long, fairly well defined process that has finally started. The process starts with recognition that there is a problem with current coverage, the gathering of peer-reviewed evidence, the evaluation of that evidence and judgment by an expert panel that the evidence is sufficient to support a change. The process then progresses to discussions of the ways coverage might change. Medicare then implements the changed coverage policies at a national level, and they are flowed down to the local regions. The process involves writing National and Local Coverage determinations, revising the HCPCS Codes, revising billing procedures, etc.-a long process. By law, the public and the stakeholder communities must be involved in every step of the process. I was gratified to see that the stakeholder community was not only involved in this important step, but was able to influence the conclusions to the good. There were still large gaps in the knowledge because the right questions were not asked and the contracted technology assessment valued process over substance. The community was given only three weeks to respond to the request for evidence, and did not have the benefit of seeing where the gaps were in the Technology Assessment before the meeting. The absence of some groups of stakeholders to submit evidence on the efficacy of their products led to gaps in the issues voted on (e.g. dielectric constant measurement of skin fluid content, ultrasound measurement of skin thickness, MRI diagnostics, low level laser treatment), and therefore a lack of recommendation of what might be promising measurement or treatment modalities to receive Medicare coverage. I hope that these information gaps will be filled in future public interactions with the CMS coverage organizations. We're on our way on a 2-3year voyage. Let's continue our research and trials to show that there is no hard line between primary and secondary lymphedema (see recent Rockson editorials), and the diagnostic and treatment techniques are the same. Let's accelerate our research and trials on diagnosis and treatment of non-extremity lymphedema (e.g. breast, torso, head and neck). Let's get more evidence of effectiveness or non-effectiveness of non-conventional treatments such as electrical/electrostatic/electromagnetic modalities, vibration modalities, laser/light therapies, and acupuncture techniques. Let's push our knowledge on hormonal and inflammation interactions with lymphedema and treatment of recurrent infection. We've taken the first step. That's the importance of the MEDCAC meeting that took place November 18. And I think it went well. Robert Weiss, MS Lymphedema Patient Advocate National Lymphedema Network The opinions expressed above are solely those of the writer, and do not reflect the policies or opinions of any organization, government agency or manufacturer. ----- Date 01/19/2010 Subject CMS Updates to Coverage Pages Content Posted information from November 18 MEDCAC meeting. Also updated Bariatric Surgery and Carotid Artery Stenting facility lists. Medicare Evidence Development & Coverage Advisory Committee (MEDCAC) Meetings 11/18/2009 - Lymphedema Posted transcript from meeting http://www.cms.hhs.gov/mcd/viewmcac.asp?where=index&mid=51 ---------------- The following are two extremely informative articles appearing in the New York Times Health Section concerning health insurance and hospital bills. In particular read the end of the first article with sound advice on filing claims of insurance denials -- much the same as I have been advising. The numbers of denials made routinely by insurers is astounding! Fighting Denied Claims Requires Perseverance http://www.nytimes.com/2010/02/06/health/06patient.html?emc=eta1 A Guide Through a Medical Wilderness http://www.nytimes.com/2009/08/08/health/08patient.html?_r=1 Bob Robert Weiss, M.S. Lymphedema Patient Advocate -------------------------- A6542 Gradient compression stocking, custom made A6543 Gradient compression stocking, lymphedema Changed HCPCS Codes A6549 Gradient compression stocking/sleeve, not otherwise specified I am not authorized to speak for Medicare or offer advice in coding or reimbursement, but the following is my interpretation of the impact of the above changes on lymphedema treatment reimbursement. There is a HCPCS group of Gradient Compression Stockings (GCS) which are listed in the 2010 HCPCS Code Book with A-codes, appropriate for Surgical Dressings. Listing does not guarantee coverage, and the majority of these items are coded with notes that indicate coverage restrictions or exclusions based on their not meeting the coverage requirements for durable medical equipment, splints and braces and surgical dressings. They are therefore denied coverage in the treatment of lymphedema in the absence of an open wound. A detailed analysis of the members of this group follows: A6530, A6533-A6541 Gradient Compression Stockings @ various styles and compression These are not covered because they do not meet the rentability requirement of SSA §1861(n) for "DME" as found in Coverage Issue #60-9/National Coverage Determination (NCD) Manual §280.1 DME List. They are excluded as "surgical dressings" when not used to treat burns per NCD §270.5. They are also excluded by the Medicare Contractor Manual (MCM section 2133 as they do not meet the rigidity requirement for "splints and braces". They are therefore not covered as surgical dressings [SSA §1861(s)(5)], durable medical equipment [SSA §1861(s)(6)] and orthotics [SSA §1861(s)(9)]. Nowhere are they excluded from coverage in their medical function in lymphedema compression therapy as prosthetic devices [SSA §1861(s)(8). A6531-A6532 Gradient Compression Stocking, Below Knee, 30-40 and 40-50 mmHg These knee-high stockings have been covered as secondary surgical dressings in the treatment of open venous wounds since 1/1/2006, when they replaced the L8110 and L8120 prosthetic device codes. Local Coverage Determinations (LCDs) exclude their coverage as surgical dressings in the treatment of lymphedema per MCM 2079/Benefit Policy Manual §100 Surgical Dressings. But this coverage criteria does not apply to prosthetic devices. A6544 Gradient Compression Stocking, Garter Belt These are not covered for the same reasons as above. A6545 Gradient Compression Wrap, Non-Elastic, Below Knee, 30-50 mmHg Thee wraps (CircAid T-3M and BiaCare CompreFit Universal Models 1101-1115 BKT/R) have been approved for coverage since 1/1/2009 and 10/30/2009 respectively, but only in the presence of open venous wounds. They have the same restrictions as A6531 and A6532 above, and must be billed with an AW Modifier, designating and open stasis wound. The 2010 pricing for this item is $89.45. The pricing codes for the three covered items is for surgical dressings, which means that a fixed reimbursement is established independent of the actual cost of the item. Medicare Suppliers must accept this fixed amount and cannot balance-bill the Beneficiary. A6542 Gradient Compression Stocking, Custom Made and A6543 and Gradient Compression Stocking Lymphedema Neither of these GCSs were covered for the same reasons stated above for A6533-A6541. Prior to the administrative code change on 1/1/2006 they were designated as prosthetic devices L8210 and L8220 and were covered. The HCPCS code has been deleted and the products described included in the A6549 Gradient Compression Stocking/Sleeve, Not Otherwise Specified. This HCPCS code is still not covered in the treatment of lymphedema in the absence of an open wound. So nothing was lost that we had before. The two deleted codes did not cover upper limb compression sleeves which were only listed with non-reimbursable S-codes. The A6549 code used to apply only to "gradient compression stockings, and the description has been broadened to include sleeves. The inclusion of both stockings and sleeves in a "not otherwise specified" category implies that the category is wide, and the reimbursement will be based on the usual cost and not a fixed amount for all items in this code. HCPCS defers pricing of these items to the DME MAC. If these items are eventually covered by Medicare as prosthetic devices, the reimbursement may be based on the price of the custom item and not a fixed reimbursement for the group. We must wait for changes in the coverage LCD and Article to define the coverage criteria t be used for this code, i.e. whether an open wound is required or whether these items, still coded with a surgical supply A-code, would be covered as prosthetic devices when used in the compression treatment of lymphedema. CMS is aware of my successful ALJ decisions supporting this interpretation. Bob Weiss ------------ Although the following letter deals with covered items such as rental items and recurring supplies, it might be prudent to follow the same procedures to support the recurring purchases of compression bandage systems, compression garments and devices, even though they are not currently covered by Medicare. Always get a prescription for these items from a PECOS listed physician and purchase them from a Medicare-enrolled Supplier if you hope to be reimbursed through the Medicare appeal system. Bob Robert Weiss, M.S. Lymphedema Patient Advocate National Lymphedema Network =========================================================== March 17, 2010 Durable Medical Equipment - Documentation of Continued Medical Necessity Dear Physician, To assure that correct payment is made for items and services that are provided to Medicare beneficiaries, the need for detailed medical documentation is paramount. If your treatment plan includes durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS), Medicare requires that suppliers have access to information from the patient's medical record that addresses the coverage criteria for the items prescribed. Accessibility of pertinent medical record information protects both the patient and the supplier in the event of an audit. For many items, Medicare coverage requires that continued use must be assessed and documented by the treating physician. Rental items such as oxygen, nebulizers, CPAP, wheelchairs, and hospital beds and recurring supplies such as glucose test strips, urological supplies, and ostomy supplies must be periodically justified in the medical record. Ongoing need for and use of the item must be documented in your patient's record in order for Medicare to continue reimbursement for the equipment or supplies. In these instances, you or your staff should regularly review the use of medical equipment and supplies by your patients. This review should be no different than your review of the continued need for medication or other treatments. Recent audits conducted by the Comprehensive Error Rate Testing program have shown that patients' medical records frequently lack sufficient information to justify the continued need for the item(s) ordered. This results in claim denials for the DMEPOS supplier and potential financial liability for your patient. When a claim is denied, the DMEPOS supplier may be unable to continue to provide the item (s) ordered. Clearly, this outcome may affect your care plan. As the patient's treating physician, it is important that you understand the applicable Medicare coverage criteria related to the DMEPOS you are prescribing and adequately document the applicable policy criteria for those items on an ongoing basis. Medicare DMEPOS Local Coverage Determinations (LCDs), which include details on specific coverage criteria, are available in the Medicare Coverage Database or on each DME MAC's Web site. Sincerely, Paul J. Hughes, M.D. Medical Director, DME MAC, Jurisdiction A Adrian M. Oleck, M.D. Medical Director, DME MAC, Jurisdiction B Robert D. Hoover, Jr., MD, MPH, FACP Medical Director, DME MAC, Jurisdiction C Richard W. Whitten, MD, MBA Medical Director, DME MAC, Jurisdiction D ---- The following announcement summarizes a change to the Medicare claims and appeals procedures that shortens the time after a service is provided for filing the initial claim: Timely Filing Requirements for Medicare Fee-For-Service Claims On March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act (PPACA), which amended the time period for filing Medicare fee-for-service (FFS) claims as one of many provisions aimed at curbing fraud, waste, and abuse in the Medicare program. Under the new law, claims for services furnished on or after January 1, 2010, must be filed within one calendar year after the date of service. In addition, Section 6404 mandates that claims for services furnished before January 1, 2010, must be filed no later than December 31, 2010. http://www.palmettogba.com/palmetto/providers.nsf/vMasterDID/844LP34117?opendocument -- Robert Weiss, MS Lymphedema Patient Advocate National Lymphedema Network LymphActivist@aol.com ------ The following letter sent to physicians writing prescriptions for DMEPOS items clearly states the requirement for documentation of the medical need for the items. Unfortunately the consequence of a physician's or supplier's non-compliance with these statutes falls on the patient, who must pay for the medical items. It is always a good idea for you, the patient, to obtain a copy of your medical records and obtain a letter of medical necessity for all compression items you need. Bob Robert Weiss, M.S. Lymphedema Patient Advocate National Lymphedema Network ======================================================== Attention Physicians Ordering Supplies! Dear Physician, The National Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Task Force would like to encourage physicians to please respond to any Comprehensive Error Rate Testing ( CERT ) documentation request they receive from CERT or the providing supplier. DMEPOS suppliers can only provide to the CERT contractor the documentation that the physicians provide to them. In order for DMEPOS suppliers to continue to provide the necessary items/service to your patient, they must be able to rely on your cooperation in providing any additional documentation requested. S ince physicians are the ones treating the beneficiaries and are responsible for maintaining records to support medical necessity of the services they provide, this typically means copies of your office notes, pertinent test reports, and other pertinent healthcare records maybe required to support the DMEPOS items/service ordered. As it is stated in the Social Security Act: Section 1833(e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider." It is expected that the patient’s medical records will reflect the need for the care provided. The patient’s medical records include the physician’s office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available upon request. When physicians are unable to provide the requested documentation, the suppliers receive denials for the items billed and their payment is recouped which could result in your patient being financially responsible for all or part of the charges for the items/service received. The DMEPOS Task Force is asking for the cooperation of the physician community. If a supplier contacts your office to request additional clinical documentation, partner with the supplier to establish what clinical records are needed to support that the service/item you ordered is medically necessary. Section 1842(p)(4) of the Social Security Act mandates that: [i]n case of an item or service…ordered by a physician or a practitioner…but furnished by another entity,If the Secretary (or fiscal agent of the Secretary) requires the entity furnishing the item or service to provide diagnostic or other medical information in order for payment to be made to the entity, the Physician or practitioner shall provide that information to the entity at the time that the item or service is ordered by the physician or practitioner. Providing medical records to the supplier is not a violation of the HIPAA Privacy Rule. Thank you for your cooperation in future documentation requests. The National DMEPOES Task Force ------- April 14, 2010 Medicare Appeals – The Importance of Getting it to the Right Place at the Right Time! Over the past year, the Qualified Independent Contractor (QIC) Part B North (the processor of second – level appeals or reconsiderations) has consistently made a high rate of dismissal decisions. Based on data analysis, the driving factor in this high rate is that appellants, primarily providers, request reconsideration when a redetermination (first level appeal performed by CIGNA Government Services following the processing of the original claim) has not been completed. While often the cause appears to be simply confusion over the steps of the appeals process and the parties involved, we have also noted that some providers are confusing written and telephone inquiry responses from CIGNA Government Services with official redetermination decisions. In accordance with current instructions, contractors are required to issue a written notice of redetermination. If you disagree with this decision, you may then file a reconsideration request in writing with the QIC. Please remember….. Your first level appeal, a redetermination, is performed by the contractor who processed the original claim and those requests should be sent directly to CIGNA Government Services. Sending a first level appeal request to the QIC will result in a dismissal. * You have 120 days from the date of receipt of the Remittance Advice to request a redetermination. You do not get extra days if you send it to the wrong entity (i.e. if you send it to the QIC and subsequently receive a dismissal for no redetermination, the 120 day clock is still ticking against the original claim process date). * The Medicare Redetermination Notice (MRN) should specifically reference the date of the original decision, state a clear decision of favorable, partially favorable, unfavorable or dismissed, and advise of any further appeal rights with the QIC’s address. Please review the entire MRN carefully. * Your request for a second level appeal, a reconsideration, should be sent directly to the QIC at the address in the MRN, within 180 days of receipt of the notice. It is helpful if you include a copy of the redetermination decision. Lastly, please be sure your request details specifically all the claims you are requesting an appeal on, including the beneficiary’s name, the Medicare Health Insurance claim number, the dates of service at issue, the services at issue, your reason for appealing, the name and signature of the party or representative of the party, and the name of the contractor that made the redetermination. Bob Robert Weiss, M.S. Lymphedema Patient Advocate National Lymphedema Network ------------------------------- Extension of Therapy Cap Exceptions Process Section 3103 of the Patient Protection and Affordable Care Act extends the exceptions process for outpatient therapy caps. Outpatient therapy service providers may continue to submit claims with the KX modifier, when an exception is appropriate, for services furnished on or after January 1, 2010, through December 31, 2010. Therapy caps are determined on a calendar year basis, so all patients began a new cap year on January 1, 2010. For physical therapy and speech language pathology services combined, the limit on incurred expenses is $1,860. For occupational therapy services, the limit is $1,860. Deductible and coinsurance amounts applied to therapy services count toward the amount accrued before a cap is reached. Bob Robert Weiss, M.S. Lymphedema Patient Advocate National Lymphedema Network |
Medicare Advantage premiums to dip in 2011
..By Susan Heavey Susan Heavey – Tue Sep 21, 4:46 pm ET
WASHINGTON (Reuters) – Elderly and disabled Americans enrolled in private Medicare health insurance
plans will pay slightly lower premiums in 2011 while gaining more benefits from recently passed healthcare
reforms, U.S. health officials said on Tuesday.
The plans, called Medicare Advantage, are offered by health insurance companies as an alternative to
traditional, government fee-for-service Medicare. Rates are expected to be 1 percent lower next year than
in 2010, the government's Centers for Medicare and Medicaid Services (CMS) said.
Enrollment in the plans is expected to grow 5 percent. More than 11 million people are already enrolled in
the plans, which have come under fire from critics who say the government pays too much to the companies
running them.
Jonathan Blum, director of CMS' Center for Medicare, said the lower costs and projected expansion show
that companies are still interested in offering such plans despite new consumer protections under the
healthcare law and recent payment caps to insurers.
"This is still a very attractive marketplace for Medicare Advantage plans," he told reporters.
Companies such as Humana Inc and UnitedHealth Group Inc are some of the biggest providers of such
plans.
Shares of health insurers were up more than 1 percent on both the Morgan Stanley Healthcare Payor Index
and the S&P Managed Health Care Index, outpacing the stock market overall.
Stifel Nicolaus analyst Thomas Carroll said the government's announcement was "in line with our view of
what the competitive environment will be like next year."
The companies, Carroll said, appear poised to endure some margin deterioration in order to boost market
share, just as the post-war baby boomer population becomes eligible for Medicare.
The news comes as the healthcare reform law, passed in March, hits its six-month anniversary this week,
triggering a host of changes for insurers overall, such as ending lifetime coverage caps and banning policy
cancellations after an enrollee gets sick.
Under the law, Medicare Advantage consumers will see their out-of-pocket expenses limited and a
reduction in how much they have to share costs when it comes to kidney dialysis, chemotherapy and other
expensive care, Blum said.
Starting in January, enrollees can also see greater discounts for prescription drugs sold either as a separate
Part D plan or as part of bundled Medicare Advantage coverage.
The healthcare law offers a 50 percent discount from drugmakers in the so-called 'donut hole' when drug
benefits temporarily stop. Officials also said more insurers were expected to offer plans that covered the
gap.
Overall, about 5 percent of beneficiaries will have to choose a new provider because their Medicare
Advantage plan has shut down, officials said.
The insurance industry warned, however, that seniors can expect more costs and fewer benefits with
Medicare Advantage plans after payment freezes have more time to take effect.
"As deep cuts go into effect in the coming years, government experts have forecasted that millions of
seniors will experience higher costs, reduced benefits and fewer choices," America's Health Insurance Plans
President and CEO Karen Ignagni said in a statement.
The group, along with its insurer members, fought against many of the healthcare reforms before they
passed but now says it is committed to implementing the law.
The government's Centers for Medicare and Medicaid Services said some companies chose to abandon
the Medicare business next year, mostly those offering private fee-for-service plans that wanted to increase
beneficiaries' costs while increasing profit margins.
About 300 out of 2,100 plans were not allowed to offer plans unless companies agreed to change them,
officials said. Most agreed to make changes, but others did not.
(Reporting by Susan Heavey; Additional reporting Lewis Krauskopf; Editing by Dave Zimmerman, Gary
Hill)
The following presents a rare opportunity to get your suggestions considered regarding changes to the
Medicare coverage and billing of physical and occupational therapy protocols for treatment of
lymphedema. You have a chance to do more than just complain about reimbursement for lymphedema
services you provide.Are you happy with your reimbursement for: Patient instruction in home self care;
Time for measurement of swelling, skin tone, bioimpedance, etc.; Time in bandaging; Cost of bandages
used incident to your services (as distinguished from the bandages provided as replacements for home use)
[issue: billing Part B VS DME]; Compression garment measurement, fitting, specification, evaluation?Do
you feel that there should be special qualifications for lymphedema providers?Should there be a separate
code for CDT and MLD other than 97140 to distinguish these procedures from other physical therapy and
rehabilitation procedures?Should there be coordination between the services provided under 97140 and
97016?Do you feel that the goals of physical therapy and rehabilitation and the goals of
complexdecongestive therapy should be distinguished from each other and policies reflect that distinction?
Meetings are scheduled in Mid October where you can present your comments and propose changes to
the Palmetto Medical Directors, and then there will be a 6-week comment period to submit formal
comments.J1 Part B LCD DL28290 Comment Period Start October 15
Share with your staff - The comment period for J1 Part B Local Coverage
Determination (LCD) Physical Medicine and Rehabilitation Policy DL28290
will begin on October 15 and end on December 3, 2010.
http://www.palmettogba.com/palmetto/providers.nsf/ls/J1B~89GQLZ0524?opendocument
OPEN DRAFT LCD MEETINGS OCTOBER 2010
Palmetto GBA J1 A/B Medicare Administrative Contractor (MAC) has scheduled Open Draft Local
Coverage Determination (LCD) meetings in the following areas in October 2010. The general public is
invited to submit information related to the proposed LCDs for Palmetto GBA's consideration. The draft
LCDs will be posted in the next few weeks on our Web site.
LCDs are administrative and educational tools that assist providers, physicians and suppliers in submitting
correct Medicare claims for coverage.
California
Time: 9 a.m. to 11 a.m. PDT on October 19, 2010
Location: Crowne Plaza San Francisco International Airport, 1177 Airport Blvd., Burlingame, CA 94010
Hawaii
Time: 8 a.m. to 10 a.m. HDT on October 14, 2010
Location: The Pacific Club, 1451 Queen Emma Street, Honolulu, HI 96813
Nevada
Time: 9 a.m. to 11 a.m. PDT on October 21, 2010
Location: Nevada State Medical Association, 2590 E. Russell Road, Las Vegas, NV 89120
Robert Weiss, M.S.
Lymphedema Treatment Advocate
National Lymphedema Network
A Message for North Carolina Physical Therapy Providers
This is to alert you that July 15, 2010, CMS will be releasing approximately 5,000 Comparative Billing
Reports (CBRs) studying the comparison of a provider’s utilization of the KX modifier with their peers in
their state and across the nation. A single state release will be done first, followed by a national release.
North Carolina has been chosen as the single state; approximately 70 CBRs will be disseminated initially,
with the remaining CBRs to follow. The purpose of this CBR is to educate independent Physical Therapy
providers and help prevent improper payments. A sample is attached. Please note in the sample, that
providers who have questions about the content of their CBR can call the CBR Support Team at 530-896-
7080, 8 a.m. to 5 p.m. local time. They can also get answers to their frequently asked questions by visiting
the CBR Services website at www.cbrservices.com
Click here for the sample file
http://www.cignagov ernmentservices. com/partb/ pubs/pdf/ A-CBR001. pdf
CBR Services Overview
The Centers for Medicare and Medicaid Services (CMS) awarded the Comparative Billing Report (CBR)
contract to SafeGuard Services LLC (SGS). A Comparative Billing Report or CBR is a documented
analysis that shows a provider's billing pattern for various procedures or services and compares that billing
to their peers.
CMS has authorized SGS to begin producing nationwide CBRs beginning in 2010. SGS, as the CBR
Producer, has begun to develop an inventory of potential topics for study. CBRs will be produced using
national data from Medicare A, B and DME. Once each study has been completed, the CBR will be
mailed or faxed to the providers that were selected under the topic criteria. A maximum of 5,000 providers
will be selected per CBR topic. The CBR, approximately 4 pages in length will also be distributed to each
provider in a PDF format. If, after reviewing the document the provider has any questions, they would then
be able to call into the SGS CBR support team, whose contact information will be provided on each CBR.
The CBR is not intended to be punitive or sent as an indication of fraud. Rather it is intented to be a
proactive statement that will help the provider identify potential errors in their billing practice. A CBR
contains peer comparisons which can be used to provide helpful insights into their coding and billing
practices. The information provided is designed to help the provider prevent improper billing and payment.
August 19, 2010 -
Correct Coding for Pneumatic Compression Devices
Pneumatic compression devices (PCD) consist of an inflatable garment for the arm or leg and an electrical
pneumatic pump that fills the garment with compressed air. The garment is intermittently inflated and
deflated with cycle times and pressures that vary between devices. Several categories of these devices
exist. It is important to use the correct HCPCS code for the item provided.
PCDs used for the treatment of lymphedema and chronic venous insufficiency with ulcers are coded based
upon the characteristics of the base device. The codes used are:
• E0650 - PNEUMATIC COMPRESSOR, NON-SEGMENTAL HOME MODEL
• E0651 - PNEUMATIC COMPRESSOR, SEGMENTAL HOME MODEL WITHOUT
CALIBRATED GRADIENT PRESSURE
• E0652 - PNEUMATIC COMPRESSOR, SEGMENTAL HOME MODEL WITH
CALIBRATED GRADIENT PRESSURE
PCDs used for the treatment of arterial disease are coded:
• E0675 - PNEUMATIC COMPRESSION DEVICE, HIGH PRESSURE, RAPID
INFLATION/DEFLATION CYCLE,FOR ARTERIAL INSUFFICIENCY (UNILATERAL AND
BILATERAL SYSTEM)
Sleeves used with E0650 - E0652 and E0675 are billed separately using codes E0655 - E0673 depending
upon the specific item provided.
There are other types of PCDs that are often referred to as deep vein thrombosis (DVT) pumps, massage
therapy pumps, post surgical DVT preventative pumps, etc. (not all inclusive). These types of devices are
coded:
• E0676 - INTERMITTENT LIMB COMPRESSION DEVICE (INCLUDES ALL
ACCESSORIES), NOT OTHERWISE SPECIFIED
The garments/sleeves that are used with E0676 are included in the payment for E0676 and must not be
billed separately. If a supplier chooses to bill separately for the garment/sleeve, then HCPCS code A9900
- MISCELLANEOUS DME SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF
ANOTHER HCPCS CODE must be used.
HCPCS code A4600 - SLEEVE FOR INTERMITTENT LIMB COMPRESSION DEVICE,
REPLACEMENT ONLY, EACH is used only when the sleeve is being replaced, not at the time of initial
issue. This code may only be used with compressors coded with E0676. HCPCS codes E0655 - E0673
must not be used when billing for garments used with E0676 devices.
Refer to the Local Coverage Determination (LCD) and Policy Article for Pneumatic Compression Devices
for coverage and HCPCS coding requirements.
August 23, 2010 -
Physical Therapists Are First Recipients Of CMS Comparative Billing Reports
The Centers for Medicare & Medicaid Services mailed its first-ever comparative billing reports (CBRs) to
as many as 5,000 physical therapists during the week of Aug. 9, according to an Aug. 16 e-mail notice
from CMS.
The CBRs, produced by SafeGuard Services LLC and distributed by Livanta LLC under contracts with
CMS, compare providers' individual billing practices for specific procedures and services with their peer
group. CMS developed the program to reduce improper payments and to educate providers on Medicare
billing requirements.
CMS has issued similar reports in the past, including the Program for Evaluating Payment Patterns
Electronic Report (PEPPER) sent to inpatient hospitals, and Resource-Based Relative Value Scale
(RBRVS) feedback reports sent to physicians, but this is the first time CMS has issued CBRs, agency
spokesman Peter Ashkenaz told BNA Aug. 17.
The initial CBRs apply to outpatient physical therapy services provided by independent physical therapists
and are based on 2009 Medicare claims data.
Physical therapists were chosen due to an identified vulnerability in their billing procedures centered on use
of the KX modifier. The KX modifier is required to indicate that a service was medically necessary and
justified by medical records, that the physical therapy financial limitation cap was met, and that a patient's
condition requires further treatment.
Moving forward, SafeGuard will produce and send new CBRs to Livanta each month for distribution to
providers.
By James Swann
Information on the CBR program is at http://www.safeguard-servicesllc.com/cbr/default.asp.
Medicare Provider-Centered Comparative Billing Report (CBR)
Last week, the Centers for Medicare & Medicaid Services mailed Comparative Billing Reports (CBRs) to
up to 5000 physical therapists across the country. The reports provide comparative data on how an
individual health care provider varies from other providers by looking at utilization patterns. We have heard
from a number of providers that this kind of information is very helpful to them and have encouraged us to
produce more CBRs and make them available to providers.
These reports are not available to anyone but the provider who received them. To ensure privacy, CMS
presents only summary billing information. No patient or case-specific data is included. A sample is
provided in this communication. These are tools to help providers comply with Medicare billing rules and
improve the level of care they furnish to their patients, our beneficiaries.
Provider Help Desk
CBR Support Team at 530-896-7080
CBR Services website at www.cbrservices.com
September 2, 2010 -
The following policy article applies only to claims made for Medicare Part a or Part B services (not
DMEPOS) but has some valuable information for all Beneficiaries who have or are contemplating sending
in claims because their provider or supplier says they are not covered.
MM6874- Beneficiary-Submitted Claims
This article, based on Change Request (CR) 6874, clarifies instructions for processing claims by carriers
and A/B MACs that are submitted by Medicare beneficiaries. All providers and suppliers are required to
enroll in the Medicare program in order to receive payment. In addition, Section 1848 (g)(4)(A) of the
Social Security Act requires all providers and suppliers submit claims for services rendered to Medicare
beneficiaries. The current manual requirement instructs Medicare contractors how to process claims
submitted by Medicare beneficiaries when the provider or supplier refuses to submit claims for services
rendered and/or refuses to enroll in Medicare. Read more at http://www.cms.
gov/MLNMattersArticles/downloads/MM6874.pdf.
..By Susan Heavey Susan Heavey – Tue Sep 21, 4:46 pm ET
WASHINGTON (Reuters) – Elderly and disabled Americans enrolled in private Medicare health insurance
plans will pay slightly lower premiums in 2011 while gaining more benefits from recently passed healthcare
reforms, U.S. health officials said on Tuesday.
The plans, called Medicare Advantage, are offered by health insurance companies as an alternative to
traditional, government fee-for-service Medicare. Rates are expected to be 1 percent lower next year than
in 2010, the government's Centers for Medicare and Medicaid Services (CMS) said.
Enrollment in the plans is expected to grow 5 percent. More than 11 million people are already enrolled in
the plans, which have come under fire from critics who say the government pays too much to the companies
running them.
Jonathan Blum, director of CMS' Center for Medicare, said the lower costs and projected expansion show
that companies are still interested in offering such plans despite new consumer protections under the
healthcare law and recent payment caps to insurers.
"This is still a very attractive marketplace for Medicare Advantage plans," he told reporters.
Companies such as Humana Inc and UnitedHealth Group Inc are some of the biggest providers of such
plans.
Shares of health insurers were up more than 1 percent on both the Morgan Stanley Healthcare Payor Index
and the S&P Managed Health Care Index, outpacing the stock market overall.
Stifel Nicolaus analyst Thomas Carroll said the government's announcement was "in line with our view of
what the competitive environment will be like next year."
The companies, Carroll said, appear poised to endure some margin deterioration in order to boost market
share, just as the post-war baby boomer population becomes eligible for Medicare.
The news comes as the healthcare reform law, passed in March, hits its six-month anniversary this week,
triggering a host of changes for insurers overall, such as ending lifetime coverage caps and banning policy
cancellations after an enrollee gets sick.
Under the law, Medicare Advantage consumers will see their out-of-pocket expenses limited and a
reduction in how much they have to share costs when it comes to kidney dialysis, chemotherapy and other
expensive care, Blum said.
Starting in January, enrollees can also see greater discounts for prescription drugs sold either as a separate
Part D plan or as part of bundled Medicare Advantage coverage.
The healthcare law offers a 50 percent discount from drugmakers in the so-called 'donut hole' when drug
benefits temporarily stop. Officials also said more insurers were expected to offer plans that covered the
gap.
Overall, about 5 percent of beneficiaries will have to choose a new provider because their Medicare
Advantage plan has shut down, officials said.
The insurance industry warned, however, that seniors can expect more costs and fewer benefits with
Medicare Advantage plans after payment freezes have more time to take effect.
"As deep cuts go into effect in the coming years, government experts have forecasted that millions of
seniors will experience higher costs, reduced benefits and fewer choices," America's Health Insurance Plans
President and CEO Karen Ignagni said in a statement.
The group, along with its insurer members, fought against many of the healthcare reforms before they
passed but now says it is committed to implementing the law.
The government's Centers for Medicare and Medicaid Services said some companies chose to abandon
the Medicare business next year, mostly those offering private fee-for-service plans that wanted to increase
beneficiaries' costs while increasing profit margins.
About 300 out of 2,100 plans were not allowed to offer plans unless companies agreed to change them,
officials said. Most agreed to make changes, but others did not.
(Reporting by Susan Heavey; Additional reporting Lewis Krauskopf; Editing by Dave Zimmerman, Gary
Hill)
The following presents a rare opportunity to get your suggestions considered regarding changes to the
Medicare coverage and billing of physical and occupational therapy protocols for treatment of
lymphedema. You have a chance to do more than just complain about reimbursement for lymphedema
services you provide.Are you happy with your reimbursement for: Patient instruction in home self care;
Time for measurement of swelling, skin tone, bioimpedance, etc.; Time in bandaging; Cost of bandages
used incident to your services (as distinguished from the bandages provided as replacements for home use)
[issue: billing Part B VS DME]; Compression garment measurement, fitting, specification, evaluation?Do
you feel that there should be special qualifications for lymphedema providers?Should there be a separate
code for CDT and MLD other than 97140 to distinguish these procedures from other physical therapy and
rehabilitation procedures?Should there be coordination between the services provided under 97140 and
97016?Do you feel that the goals of physical therapy and rehabilitation and the goals of
complexdecongestive therapy should be distinguished from each other and policies reflect that distinction?
Meetings are scheduled in Mid October where you can present your comments and propose changes to
the Palmetto Medical Directors, and then there will be a 6-week comment period to submit formal
comments.J1 Part B LCD DL28290 Comment Period Start October 15
Share with your staff - The comment period for J1 Part B Local Coverage
Determination (LCD) Physical Medicine and Rehabilitation Policy DL28290
will begin on October 15 and end on December 3, 2010.
http://www.palmettogba.com/palmetto/providers.nsf/ls/J1B~89GQLZ0524?opendocument
OPEN DRAFT LCD MEETINGS OCTOBER 2010
Palmetto GBA J1 A/B Medicare Administrative Contractor (MAC) has scheduled Open Draft Local
Coverage Determination (LCD) meetings in the following areas in October 2010. The general public is
invited to submit information related to the proposed LCDs for Palmetto GBA's consideration. The draft
LCDs will be posted in the next few weeks on our Web site.
LCDs are administrative and educational tools that assist providers, physicians and suppliers in submitting
correct Medicare claims for coverage.
California
Time: 9 a.m. to 11 a.m. PDT on October 19, 2010
Location: Crowne Plaza San Francisco International Airport, 1177 Airport Blvd., Burlingame, CA 94010
Hawaii
Time: 8 a.m. to 10 a.m. HDT on October 14, 2010
Location: The Pacific Club, 1451 Queen Emma Street, Honolulu, HI 96813
Nevada
Time: 9 a.m. to 11 a.m. PDT on October 21, 2010
Location: Nevada State Medical Association, 2590 E. Russell Road, Las Vegas, NV 89120
Robert Weiss, M.S.
Lymphedema Treatment Advocate
National Lymphedema Network
A Message for North Carolina Physical Therapy Providers
This is to alert you that July 15, 2010, CMS will be releasing approximately 5,000 Comparative Billing
Reports (CBRs) studying the comparison of a provider’s utilization of the KX modifier with their peers in
their state and across the nation. A single state release will be done first, followed by a national release.
North Carolina has been chosen as the single state; approximately 70 CBRs will be disseminated initially,
with the remaining CBRs to follow. The purpose of this CBR is to educate independent Physical Therapy
providers and help prevent improper payments. A sample is attached. Please note in the sample, that
providers who have questions about the content of their CBR can call the CBR Support Team at 530-896-
7080, 8 a.m. to 5 p.m. local time. They can also get answers to their frequently asked questions by visiting
the CBR Services website at www.cbrservices.com
Click here for the sample file
http://www.cignagov ernmentservices. com/partb/ pubs/pdf/ A-CBR001. pdf
CBR Services Overview
The Centers for Medicare and Medicaid Services (CMS) awarded the Comparative Billing Report (CBR)
contract to SafeGuard Services LLC (SGS). A Comparative Billing Report or CBR is a documented
analysis that shows a provider's billing pattern for various procedures or services and compares that billing
to their peers.
CMS has authorized SGS to begin producing nationwide CBRs beginning in 2010. SGS, as the CBR
Producer, has begun to develop an inventory of potential topics for study. CBRs will be produced using
national data from Medicare A, B and DME. Once each study has been completed, the CBR will be
mailed or faxed to the providers that were selected under the topic criteria. A maximum of 5,000 providers
will be selected per CBR topic. The CBR, approximately 4 pages in length will also be distributed to each
provider in a PDF format. If, after reviewing the document the provider has any questions, they would then
be able to call into the SGS CBR support team, whose contact information will be provided on each CBR.
The CBR is not intended to be punitive or sent as an indication of fraud. Rather it is intented to be a
proactive statement that will help the provider identify potential errors in their billing practice. A CBR
contains peer comparisons which can be used to provide helpful insights into their coding and billing
practices. The information provided is designed to help the provider prevent improper billing and payment.
August 19, 2010 -
Correct Coding for Pneumatic Compression Devices
Pneumatic compression devices (PCD) consist of an inflatable garment for the arm or leg and an electrical
pneumatic pump that fills the garment with compressed air. The garment is intermittently inflated and
deflated with cycle times and pressures that vary between devices. Several categories of these devices
exist. It is important to use the correct HCPCS code for the item provided.
PCDs used for the treatment of lymphedema and chronic venous insufficiency with ulcers are coded based
upon the characteristics of the base device. The codes used are:
• E0650 - PNEUMATIC COMPRESSOR, NON-SEGMENTAL HOME MODEL
• E0651 - PNEUMATIC COMPRESSOR, SEGMENTAL HOME MODEL WITHOUT
CALIBRATED GRADIENT PRESSURE
• E0652 - PNEUMATIC COMPRESSOR, SEGMENTAL HOME MODEL WITH
CALIBRATED GRADIENT PRESSURE
PCDs used for the treatment of arterial disease are coded:
• E0675 - PNEUMATIC COMPRESSION DEVICE, HIGH PRESSURE, RAPID
INFLATION/DEFLATION CYCLE,FOR ARTERIAL INSUFFICIENCY (UNILATERAL AND
BILATERAL SYSTEM)
Sleeves used with E0650 - E0652 and E0675 are billed separately using codes E0655 - E0673 depending
upon the specific item provided.
There are other types of PCDs that are often referred to as deep vein thrombosis (DVT) pumps, massage
therapy pumps, post surgical DVT preventative pumps, etc. (not all inclusive). These types of devices are
coded:
• E0676 - INTERMITTENT LIMB COMPRESSION DEVICE (INCLUDES ALL
ACCESSORIES), NOT OTHERWISE SPECIFIED
The garments/sleeves that are used with E0676 are included in the payment for E0676 and must not be
billed separately. If a supplier chooses to bill separately for the garment/sleeve, then HCPCS code A9900
- MISCELLANEOUS DME SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF
ANOTHER HCPCS CODE must be used.
HCPCS code A4600 - SLEEVE FOR INTERMITTENT LIMB COMPRESSION DEVICE,
REPLACEMENT ONLY, EACH is used only when the sleeve is being replaced, not at the time of initial
issue. This code may only be used with compressors coded with E0676. HCPCS codes E0655 - E0673
must not be used when billing for garments used with E0676 devices.
Refer to the Local Coverage Determination (LCD) and Policy Article for Pneumatic Compression Devices
for coverage and HCPCS coding requirements.
August 23, 2010 -
Physical Therapists Are First Recipients Of CMS Comparative Billing Reports
The Centers for Medicare & Medicaid Services mailed its first-ever comparative billing reports (CBRs) to
as many as 5,000 physical therapists during the week of Aug. 9, according to an Aug. 16 e-mail notice
from CMS.
The CBRs, produced by SafeGuard Services LLC and distributed by Livanta LLC under contracts with
CMS, compare providers' individual billing practices for specific procedures and services with their peer
group. CMS developed the program to reduce improper payments and to educate providers on Medicare
billing requirements.
CMS has issued similar reports in the past, including the Program for Evaluating Payment Patterns
Electronic Report (PEPPER) sent to inpatient hospitals, and Resource-Based Relative Value Scale
(RBRVS) feedback reports sent to physicians, but this is the first time CMS has issued CBRs, agency
spokesman Peter Ashkenaz told BNA Aug. 17.
The initial CBRs apply to outpatient physical therapy services provided by independent physical therapists
and are based on 2009 Medicare claims data.
Physical therapists were chosen due to an identified vulnerability in their billing procedures centered on use
of the KX modifier. The KX modifier is required to indicate that a service was medically necessary and
justified by medical records, that the physical therapy financial limitation cap was met, and that a patient's
condition requires further treatment.
Moving forward, SafeGuard will produce and send new CBRs to Livanta each month for distribution to
providers.
By James Swann
Information on the CBR program is at http://www.safeguard-servicesllc.com/cbr/default.asp.
Medicare Provider-Centered Comparative Billing Report (CBR)
Last week, the Centers for Medicare & Medicaid Services mailed Comparative Billing Reports (CBRs) to
up to 5000 physical therapists across the country. The reports provide comparative data on how an
individual health care provider varies from other providers by looking at utilization patterns. We have heard
from a number of providers that this kind of information is very helpful to them and have encouraged us to
produce more CBRs and make them available to providers.
These reports are not available to anyone but the provider who received them. To ensure privacy, CMS
presents only summary billing information. No patient or case-specific data is included. A sample is
provided in this communication. These are tools to help providers comply with Medicare billing rules and
improve the level of care they furnish to their patients, our beneficiaries.
Provider Help Desk
CBR Support Team at 530-896-7080
CBR Services website at www.cbrservices.com
September 2, 2010 -
The following policy article applies only to claims made for Medicare Part a or Part B services (not
DMEPOS) but has some valuable information for all Beneficiaries who have or are contemplating sending
in claims because their provider or supplier says they are not covered.
MM6874- Beneficiary-Submitted Claims
This article, based on Change Request (CR) 6874, clarifies instructions for processing claims by carriers
and A/B MACs that are submitted by Medicare beneficiaries. All providers and suppliers are required to
enroll in the Medicare program in order to receive payment. In addition, Section 1848 (g)(4)(A) of the
Social Security Act requires all providers and suppliers submit claims for services rendered to Medicare
beneficiaries. The current manual requirement instructs Medicare contractors how to process claims
submitted by Medicare beneficiaries when the provider or supplier refuses to submit claims for services
rendered and/or refuses to enroll in Medicare. Read more at http://www.cms.
gov/MLNMattersArticles/downloads/MM6874.pdf.
The Amount in Controversy (AIC) required to sustain Administrative Law Judge (ALJ) and Federal
District Court appeal rights beginning January 1, 2010. o The amount remaining in controversy
requirement for ALJ hearing requests made before January 1, 2010, is $120. The amount remaining in
controversy requirement for requests made on or after January 1, 2010, is $130. o For Federal District
Court review, the amount remaining in controversy goes from $1,220 for requests on or after January
1, 2009, to $1,260 for requests on or after January 1, 2010. That means that when you file a Medicare
appeal make sure that you combine all the items in a single appeal. You can combine claims so long as
they are all within the filing time window. And remember that the Amount In Appeal is the cost of the
material less your 20% co-pay, so if you want to eventually be considered by an ALJ your appeal must
be for an aggragate amount of greater than $163.00 Bob Robert Weiss, M.S. Lymphedema Patient
Advocate National Lymphedema Network
-----------------------
May 20, 2010
Therapeutic Shoes - In-Person Fitting and Delivery
Appendix C of the DMEPOS Quality Standards published in October 2008 addresses specific
requirements for orthoses, prostheses, prosthetic devices, and therapeutic shoes. Those standards
include requirements for "an in-person diagnosis-specific functional clinical examination" by the supplier
to determine the need for a particular item as well as "face-to-face fitting/delivery" by the supplier.
Therefore, in order for therapeutic shoes, inserts, and shoe modifications to be covered, both of the
following criteria must be met:
1.Prior to selecting the specific items that will be provided, the supplier must conduct and document an
in-person evaluation of the patient; and,
2.At the time of delivery of the items selected, the supplier must conduct and document an in-person
visit with the patient to ensure that the shoes/inserts/ modifications are properly fit and meet the
beneficiary' s needs.
In order to meet these criteria, effective for claims with dates of service on or after July 1 , 2010, the
following documentation requirements must be met:
•The in-person evaluation prior to selecting the items must include at least an examination of the
patient's feet with a description of the abnormalities that will need to be accommodated by the
shoes/inserts/ modifications. For all shoes, it must include taking measurements of the patient's feet. For
custom molded shoes (A5501) and inserts (A5513), this visit must also include taking impressions,
making casts, or obtaining CAD-CAM images of the patient's feet that will be used in creating positive
models of the feet.
•The in-person visit at the time of delivery must include an assessment of the fit of the shoes and inserts
with the patient wearing them.
Depending on the items ordered, both the evaluation and delivery could occur on the same day if the
supplier had both a sufficient array of sizes and types of shoes/inserts and adequate equipment on site
to provide the items that meet the beneficiary' s needs. Both components of the visit (criteria 1 and 2,
above) must be clearly documented.
Documentation of these visits must be available to the DME MAC, PSC/ZPIC, RAC, or CERT
contractor on request. If one or more of these requirements are not met, the claim will be denied as
statutorily noncovered.
This information will be incorporated in a future revision of the Therapeutic Shoes policy. Refer to the
Therapeutic Shoes Local Coverage Determination and Policy Article for additional information
regarding coverage, coding, and documentation.
From: NHIC DME MAC A
Robert Weiss, MS
Lymphedema Patient Advocate
National Lymphedema Network
__._,_.___
==========================
The revised Rehabilitation Therapy Information Resource for Medicare Fact Sheet (April 2010) is now
available in downloadable format from the Centers for Medicare & Medicaid Services? Medicare
Learning Network at http://www.cms. gov/MLNProducts/ downloads/ Rehab_Therapy_ Fact_Sheet.
pdf on the CMS website. This fact sheet provides guidance and resources related to rehabilitation
therapy services, coverage requirements, and payment systems.
-------------------
Change in the Amount in Controversy (AIC) Requirement for Administrative Law Judge Hearings and
Federal District Court Appeals
MLN Matters® Number: MM6894
Related Change Request (CR) #: 6894
Related CR Release Date: May 7, 2010
Effective Date: August 9, 2010
Related CR Transmittal #: R1965CP
Implementation Date: August 9, 2010
Provider Types Affected
Physicians, providers and suppliers submitting claims to Medicare carriers, Durable Medical Equipment
Medicare Administrative Contractors (DME MACs), Fiscal Intermediaries (FIs), Part A/B MACs
(A/B MACs) and/or Regional Home Health Intermediaries (RHHIs) for services provided to Medicare
beneficiaries are affected.
Provider Action Needed
This article is based on Change Request (CR) 6894, which notifies Medicare contractors of the
Amount in Controversy (AIC) required to sustain Administrative Law Judge (ALJ) and Federal District
Court appeal rights beginning January 1, 2010.
The amount remaining in controversy requirement for ALJ hearing requests made before January 1,
2010, is $120. The amount remaining in controversy requirement for requests made on or after January
1, 2010, is $130.
For Federal District Court review, the amount remaining in controversy goes from $1,220 for requests
on or after January 1, 2009, to $1,260 for requests on or after January 1, 2010
Please sure that your staff knows of these changes.
Background
The Medicare claims appeal process was amended by the Medicare, Medicaid and SCHIP Benefits
Improvement and Protection Act of 2000 (BIPA). CR 6894 modifies the Medicare Claims Processing
Manual, Chapter 29, Sections 220, 330.1 and 345.1 to update the AIC required for an ALJ hearing or
judicial court review. CR 6894 also expands the background information in the Amount in Controversy
General Requirements, Principles for Determining Amount in Controversy and Aggregation of Claims
to meet Amount in Controversy sections 250, 250.1, 250.2 and 250.3 in the Claims Processing
Manual, Chapter 29. The revised portions of the manual are attached to CR 6894.
Additional Information
The official instruction (CR 6894) issued to your Medicare Carrier, A/B MAC, DME MAC, FI and/or
RHHI is available at www.cms.gov/Transmittals/downloads/R1965CP.pdf on the Centers for
Medicare & Medicaid Services (CMS) Web site.
A brochure entitled, The Medicare Appeals Process: Five Levels To Protect Providers, Physicians
And Other Suppliers provides an overview of the Medicare Part A and Part B administrative appeals
process available to providers, physicians and other suppliers who provide services and supplies to
Medicare beneficiaries, as well as details on where to obtain more information about this appeals
process. The brochure is available at www.cms.hhs.
gov/MLNProducts/downloads/MedicareAppealsProcess.pdf on the CMS Web site.
The brochure is a very well done information source.
Bob
Robert Weiss, M.S.
Lymphedema Patient Advocate
National Lymphedema Network
--------------
The topic of Medicare limits on therapy comes up very often, and I wish to comment. My comments
apply to current Medicare policy, but to the extent that the principles apply to lymphedema medical
treatment in general, they may be able to be used for private insurance too.
Medicare has a policy this year called the "exception" rule which allows therapy beyond the annual
$1860 limit when the additional treatments are deemed "medically necessary" by the treating physician.
The additional treatments might be necessary because there are other co-conditions which make the
therapy less efficient, force the therapy to be done slower than usual, extend to multiple body sites, etc.
This is all assuming that the therapist is qualified and competent, and is teaching the patient to do home
self-treatment between clinical sessions.
Some of these co-conditions might be congestive heart failure, venous insufficiency, peripheral arterial
disease, obesity, lipodema, multiple limbs or body sites, diabetes, etc.
If Medicare turns you down ask your physician to write a letter of medical necessity for additional
treatments because these co-morbidities make the treatment less efficient and therefore require therapy
exceeding the statutory (policy for insurance) limits.
Medicare will reimburse ANY physical therapist or occupational therapist why treats a lymphedema
patient regardless of whether that therapist has the specialized lymphedema training. This occasionally
results in treatment that may not be effective, and the patient reaches the annual limits without
experiencing the improvement that would be expected from a properly qualified therapist.
ALWAYS check whether the lymphedema therapist has had adequate training and experience, and if
not, find one who has. The LANA national certification for lymphedema therapists requires a minimum
of 135 hours of lymphedema training on top of a current license in physical or occupational therapy plus
one year of clinical experience overseen by a qualified lymphedema therapist.
Bob
Robert Weiss, M.S.
Lymphedema Patient Advocate
National Lymphedema Network
District Court appeal rights beginning January 1, 2010. o The amount remaining in controversy
requirement for ALJ hearing requests made before January 1, 2010, is $120. The amount remaining in
controversy requirement for requests made on or after January 1, 2010, is $130. o For Federal District
Court review, the amount remaining in controversy goes from $1,220 for requests on or after January
1, 2009, to $1,260 for requests on or after January 1, 2010. That means that when you file a Medicare
appeal make sure that you combine all the items in a single appeal. You can combine claims so long as
they are all within the filing time window. And remember that the Amount In Appeal is the cost of the
material less your 20% co-pay, so if you want to eventually be considered by an ALJ your appeal must
be for an aggragate amount of greater than $163.00 Bob Robert Weiss, M.S. Lymphedema Patient
Advocate National Lymphedema Network
-----------------------
May 20, 2010
Therapeutic Shoes - In-Person Fitting and Delivery
Appendix C of the DMEPOS Quality Standards published in October 2008 addresses specific
requirements for orthoses, prostheses, prosthetic devices, and therapeutic shoes. Those standards
include requirements for "an in-person diagnosis-specific functional clinical examination" by the supplier
to determine the need for a particular item as well as "face-to-face fitting/delivery" by the supplier.
Therefore, in order for therapeutic shoes, inserts, and shoe modifications to be covered, both of the
following criteria must be met:
1.Prior to selecting the specific items that will be provided, the supplier must conduct and document an
in-person evaluation of the patient; and,
2.At the time of delivery of the items selected, the supplier must conduct and document an in-person
visit with the patient to ensure that the shoes/inserts/ modifications are properly fit and meet the
beneficiary' s needs.
In order to meet these criteria, effective for claims with dates of service on or after July 1 , 2010, the
following documentation requirements must be met:
•The in-person evaluation prior to selecting the items must include at least an examination of the
patient's feet with a description of the abnormalities that will need to be accommodated by the
shoes/inserts/ modifications. For all shoes, it must include taking measurements of the patient's feet. For
custom molded shoes (A5501) and inserts (A5513), this visit must also include taking impressions,
making casts, or obtaining CAD-CAM images of the patient's feet that will be used in creating positive
models of the feet.
•The in-person visit at the time of delivery must include an assessment of the fit of the shoes and inserts
with the patient wearing them.
Depending on the items ordered, both the evaluation and delivery could occur on the same day if the
supplier had both a sufficient array of sizes and types of shoes/inserts and adequate equipment on site
to provide the items that meet the beneficiary' s needs. Both components of the visit (criteria 1 and 2,
above) must be clearly documented.
Documentation of these visits must be available to the DME MAC, PSC/ZPIC, RAC, or CERT
contractor on request. If one or more of these requirements are not met, the claim will be denied as
statutorily noncovered.
This information will be incorporated in a future revision of the Therapeutic Shoes policy. Refer to the
Therapeutic Shoes Local Coverage Determination and Policy Article for additional information
regarding coverage, coding, and documentation.
From: NHIC DME MAC A
Robert Weiss, MS
Lymphedema Patient Advocate
National Lymphedema Network
__._,_.___
==========================
The revised Rehabilitation Therapy Information Resource for Medicare Fact Sheet (April 2010) is now
available in downloadable format from the Centers for Medicare & Medicaid Services? Medicare
Learning Network at http://www.cms. gov/MLNProducts/ downloads/ Rehab_Therapy_ Fact_Sheet.
pdf on the CMS website. This fact sheet provides guidance and resources related to rehabilitation
therapy services, coverage requirements, and payment systems.
-------------------
Change in the Amount in Controversy (AIC) Requirement for Administrative Law Judge Hearings and
Federal District Court Appeals
MLN Matters® Number: MM6894
Related Change Request (CR) #: 6894
Related CR Release Date: May 7, 2010
Effective Date: August 9, 2010
Related CR Transmittal #: R1965CP
Implementation Date: August 9, 2010
Provider Types Affected
Physicians, providers and suppliers submitting claims to Medicare carriers, Durable Medical Equipment
Medicare Administrative Contractors (DME MACs), Fiscal Intermediaries (FIs), Part A/B MACs
(A/B MACs) and/or Regional Home Health Intermediaries (RHHIs) for services provided to Medicare
beneficiaries are affected.
Provider Action Needed
This article is based on Change Request (CR) 6894, which notifies Medicare contractors of the
Amount in Controversy (AIC) required to sustain Administrative Law Judge (ALJ) and Federal District
Court appeal rights beginning January 1, 2010.
The amount remaining in controversy requirement for ALJ hearing requests made before January 1,
2010, is $120. The amount remaining in controversy requirement for requests made on or after January
1, 2010, is $130.
For Federal District Court review, the amount remaining in controversy goes from $1,220 for requests
on or after January 1, 2009, to $1,260 for requests on or after January 1, 2010
Please sure that your staff knows of these changes.
Background
The Medicare claims appeal process was amended by the Medicare, Medicaid and SCHIP Benefits
Improvement and Protection Act of 2000 (BIPA). CR 6894 modifies the Medicare Claims Processing
Manual, Chapter 29, Sections 220, 330.1 and 345.1 to update the AIC required for an ALJ hearing or
judicial court review. CR 6894 also expands the background information in the Amount in Controversy
General Requirements, Principles for Determining Amount in Controversy and Aggregation of Claims
to meet Amount in Controversy sections 250, 250.1, 250.2 and 250.3 in the Claims Processing
Manual, Chapter 29. The revised portions of the manual are attached to CR 6894.
Additional Information
The official instruction (CR 6894) issued to your Medicare Carrier, A/B MAC, DME MAC, FI and/or
RHHI is available at www.cms.gov/Transmittals/downloads/R1965CP.pdf on the Centers for
Medicare & Medicaid Services (CMS) Web site.
A brochure entitled, The Medicare Appeals Process: Five Levels To Protect Providers, Physicians
And Other Suppliers provides an overview of the Medicare Part A and Part B administrative appeals
process available to providers, physicians and other suppliers who provide services and supplies to
Medicare beneficiaries, as well as details on where to obtain more information about this appeals
process. The brochure is available at www.cms.hhs.
gov/MLNProducts/downloads/MedicareAppealsProcess.pdf on the CMS Web site.
The brochure is a very well done information source.
Bob
Robert Weiss, M.S.
Lymphedema Patient Advocate
National Lymphedema Network
--------------
The topic of Medicare limits on therapy comes up very often, and I wish to comment. My comments
apply to current Medicare policy, but to the extent that the principles apply to lymphedema medical
treatment in general, they may be able to be used for private insurance too.
Medicare has a policy this year called the "exception" rule which allows therapy beyond the annual
$1860 limit when the additional treatments are deemed "medically necessary" by the treating physician.
The additional treatments might be necessary because there are other co-conditions which make the
therapy less efficient, force the therapy to be done slower than usual, extend to multiple body sites, etc.
This is all assuming that the therapist is qualified and competent, and is teaching the patient to do home
self-treatment between clinical sessions.
Some of these co-conditions might be congestive heart failure, venous insufficiency, peripheral arterial
disease, obesity, lipodema, multiple limbs or body sites, diabetes, etc.
If Medicare turns you down ask your physician to write a letter of medical necessity for additional
treatments because these co-morbidities make the treatment less efficient and therefore require therapy
exceeding the statutory (policy for insurance) limits.
Medicare will reimburse ANY physical therapist or occupational therapist why treats a lymphedema
patient regardless of whether that therapist has the specialized lymphedema training. This occasionally
results in treatment that may not be effective, and the patient reaches the annual limits without
experiencing the improvement that would be expected from a properly qualified therapist.
ALWAYS check whether the lymphedema therapist has had adequate training and experience, and if
not, find one who has. The LANA national certification for lymphedema therapists requires a minimum
of 135 hours of lymphedema training on top of a current license in physical or occupational therapy plus
one year of clinical experience overseen by a qualified lymphedema therapist.
Bob
Robert Weiss, M.S.
Lymphedema Patient Advocate
National Lymphedema Network