Article Detail - JA DME

Outlined below are the principal changes to the DME MAC Local Coverage Determinations (LCDs) and Policy Articles (PAs) that have been revised and posted. The policies included are Enteral Nutrition, Glucose Monitors, and Wheelchair Seating. Please review the entire LCDs and related PAs for complete information.

Enteral Nutrition

LCD

Revision Effective Date: 10/01/2023
COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:
Revised: Language pertinent to the feeding supply allowance corresponding to the method of administration, to add "B4148" and "elastomeric control fed"
Revised: Language pertinent to supply allowances, to add "B4148"
SUMMARY OF EVIDENCE:
Removed: Summary of evidence information, due to not being applicable to the non-discretionary changes
ANALYSIS OF EVIDENCE (RATIONALE FOR DETERMINATION):
Removed: Analysis of evidence information, due to not being applicable to the non-discretionary changes
HCPCS CODES:
Added: HCPCS code B4148

11/09/2023: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because the revisions are non-discretionary updates per CMS HCPCS coding determinations.

PA

Revision Effective Date: 10/01/2023
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Added: "B4148" to supply allowance codes
CODING GUIDELINES:
Added: "B4148" to supply allowance codes

11/09/2023: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Glucose Monitors

LCD

Revision Effective Date: 01/01/2024
COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:
Added: "or Medicare-approved telehealth" to High Utilization coverage criteria
Removed: One (1) unit of service (UOS) per thirty (30) days regarding billing for supply allowance code A4238 or A4239
Added: Three (3) UOS per ninety (90) days regarding billing for supply allowance code A4238 or A4239 and "Billing more than three (3) UOS per ninety (90) days of code A4238 or A4239 will be denied as not reasonable and necessary."
SUMMARY OF EVIDENCE:
Removed: Summary of evidence information, due to not being applicable to the non-discretionary changes
ANALYSIS OF EVIDENCE (RATIONALE FOR DETERMINATION):
Removed: Analysis of evidence information, due to not being applicable to the non-discretionary changes
BIBLIOGRAPHY:
Removed: Bibliography information, due to not being applicable to the non-discretionary changes

11/09/2023: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because they are non-discretionary.

PA

Revision Effective Date: 01/01/2024
CODING GUIDELINES:
Removed: Language regarding billing only one (1) month, thirty (30) days of the supply allowance for code A4238 or A4239
Added: Language regarding billing up to a maximum of three (3) months, ninety (90) days of the supply allowance for code A4238 or A4239

11/09/2023: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Wheelchair Seating

PA

Revision Effective Date: 12/20/2023
ICD-10-CM CODES THAT SUPPORT MEDICAL NECESSITY:
Added: Information, to Group 1 Paragraph and Group 4 Paragraph, which specifies Z87.2 ICD-10-CM code must be appended when the beneficiary has a history of a healed pressure ulcer on the area of contact with the seating surface, Z87.2 is not for use to describe a current pressure ulcer on the area of contact with the seating surface, and other ICD-10-CM codes in the Group 1 Codes and Group 4 Codes are not for use to represent a history of a healed pressure ulcer on the area of contact with the seating surface
Added: ICD-10-CM code Z87.2 to Group 1 Codes and Group 4 Codes

11/09/2023: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Note: The information contained in this article is only a summary of revisions to the LCDs and/or PAs. For complete information on any topic, you must review the LCDs and/or PAs.

With the update(s) listed above, Noridian would like to remind users how to find the policy that was previously effective. When billing, the supplier should follow guidance that was effective on the date of service. The below steps can be followed to find all previous policies:

1. Open the currently effective policy on the Medical Coverage Database (MCD)
   1. Links to the MCD can be found on the Active LCDs page on the Noridian website
      1. There is a link at the top of the Active LCD page that goes to a full list of the LCDs or PAs, depending on which link is selected OR
      2. There are direct links to all LCDs under the ‘LCD ID number and Effective Date’ column
2. Scroll down to the bottom of the policy
3. Find the section labeled Public Version(s)
4. Look for the link to the policy that was effective on the dates of service in question.
5. Click on hyperlink to go to the policy.