LCD and Policy Article Revisions Summary for March 16 2017 - JA DME
LCD and Policy Article Revisions Summary for March 16, 2017
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 Ankle-Foot/Knee-Ankle-Foot Orthosis, Bowel Management Devices, Enteral Nutrition, External Infusion Pumps, Knee Orthoses, Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics), Seat Lift Mechanisms, Spinal Orthoses: TLSO and LSO, Urological Supplies and Wheelchair Options/Accessories. Please review the entire LCD and related PA for complete information.
Ankle-Foot/Knee-Ankle-Foot Orthosis
LCD
Revision Effective Date: 01/01/2017
COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Removed: Standard Documentation Language
Added: New reference language and Directions to Standard Documentation Requirements
Added: General Requirements
HCPCS CODES:
Added: HCPCS Code A4467 & A9285
Deleted: HCPCS Code A4466
Revised: HCPCS Code L1906
ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:
Deleted: ICD-10 Diagnoses (M14.661, M14.662, M14.669) for L4631; diagnoses not pertinent to this orthosis
DOCUMENTATION REQUIREMENTS:
Removed: Standard Documentation Language
Added: General Documentation Requirements
Added: New reference language and Directions to Standard Documentation Requirements
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Removed: Standard Documentation Language
Added: Directions to Standard Documentation Requirements
Removed: Information under Miscellaneous and Appendices
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements article
Policy Article
Revision Effective Date: 01/01/2017
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised: Brace Benefit explanation to remove reference to "counterforce" that is no longer applicable
Revised: Prefabricated and off-the-shelf (OTS) "minimal self-adjustment" regulatory definition discussion to improve consistency with regulatory definition of minimal self-adjustment
Deleted: A4466
Added: A4467
Added: Instructions for A9285
Added: Policy specific documentation requirements from LCD
CODING GUIDELINES:
Removed: Reference to classification algorithm summary
Revised: OTS and custom-fit definitions to improve consistency with regulatory definition of "minimal self-adjustment"
Added: Section on coding of elastic and similar materials
Deleted: A4466
Added: A4467
Added A9285
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements Language Article
Bowel Management Devices
LCD
Revision Effective Date: 01/01/2017
COVERAGE INDICATIONS, INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Removed: Standard Documentation Language
Added: New reference language and directions to Standard Documentation Requirements
Added: General Requirements
Added: Denial language for A4553
HCPCS CODES:
Added: HCPCS Code A4553
DOCUMENTATION REQUIREMENTS:
Removed: Standard Documentation Language
Added: General Documentation Requirements
Added: New reference language and directions to Standard Documentation Requirements
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Removed: Standard Documentation Language
Added: Direction to Standard Documentation Requirements
Deleted: Sources of Information
Removed: Information under Miscellaneous and Appendices
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements article
Policy Article
Revision Effective Date: 01/01/2017
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Added: HCPCS Codes A4553 to Statutorily excluded from coverage list
Added: Policy Specific Documentation Requirements
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements Language Article
Enteral Nutrition
LCD
Revision Effective Date: 01/01/2017
COVERAGE INDICATIONS, INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Removed: Standard Documentation Language
Added: New reference language and directions to Standard Documentation Requirements
Removed: HCPCS Code B9000 from equipment and supplies documentation requirements
Added: Unbundling instructions for enteral supply allowances.
Added: General Requirements
Revised: Refill Requirements
Removed: HCPCS Code B9000 from documentation requirements
HCPCS MODIFIERS:
Deleted: Code B9000
Revised: Code narrative for HCPCS B9002
DOCUMENTATION REQUIREMENTS:
Removed: Standard Documentation Language
Added: General Documentation Requirements
Added: New reference language and directions to Standard Documentation Requirements
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Removed: Standard Documentation Language
Added: Direction to Standard Documentation Requirements
Removed: Information under Miscellaneous and Appendices
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements article
Policy Article
Revision Effective Date: 01/01/2017
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Added: Supply payment allowance for HCPCS B4034 – B4036
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: DIF requirements
Updated: Recertification DIF to revised DIF
CODING GUIDELINES:
Revised: Coding guidelines of items included in the feeding supply allowance
Added: Guidelines for blenderized and calorically dense formulations
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements Language Article
External Infusion Pumps
LCD
Revision Effective Date: 01/01/2017
COVERAGE INDICATIONS, INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Removed: Standard Documentation Language
Added: New reference language and Directions to Standard Documentation Requirements
Added: Billing instructions for A4224 and A4225
Added: General Requirements
Revised: Refill Requirements
Revised: Drug Waste verbiage
HCPCS MODIFIERS:
Added: Codes A4224 and A4225
Revised: Code narratives for HCPCS A4221, J7340 and K0552
DOCUMENTATION REQUIREMENTS:
Removed: Standard Documentation Language
Added: General Documentation Requirements
Added: New reference language and Directions to Standard Documentation Requirements
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Removed: Standard Documentation Language
Added: Direction to Standard Documentation Requirements
Removed: Information from Miscellaneous
Removed: PIM citation from under Appendices
SOURCES OF INFORMATION AND BASIS FOR DECISION:
Removed: Links
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements article
Policy Article
Revision Effective Date: 01/01/2017
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Replaced: A4221 with A4224 when using catheter insertion devices
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: 42 CFR 410.38(g), DIF and Modifiers requirements
CODING GUIDELINES:
Added: Billing instructions for A4224 and A4225
RELATED LOCAL COVERAGE DOCUMENTS:
Added: The LCD-related Standard Documentation Requirements Language Article
Knee Orthoses
LCD
Revision Effective Date: 01/01/2017
COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Removed: Standard Documentation Language
Added: New reference language and directions to Standard Documentation Requirements
Deleted: K0901 and K0902
Added: L1851 and L1852
Added: General Requirements
HCPCS CODES:
Deleted: A4466, K0901 and K0902
Added: A4467, L1851 and L1852
ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:
Deleted: K0901 and K0902 from Group 4 Paragraph
Added: L1851 and L1852 to Group 4 Paragraph
Added: ICD-10 Codes M21.861 and M21.862 to Group 5 –Effective 10/01/2015
DOCUMENTATION REQUIREMENTS:
Removed: Standard Documentation Language
Added: General Documentation Requirements
Added: New reference language and directions to Standard Documentation Requirements
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Removed: Standard Documentation Language
Added: Directions to Standard Documentation Requirements
Removed: Information under Miscellaneous and Appendices
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements article
Policy Article
Revision Effective Date: 01/01/2017
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised: Brace Benefit explanation to remove reference to "counterforce" that is no longer applicable
Revised: Prefabricated and off-the-shelf (OTS) "minimal self-adjustment" regulatory definition discussion to improve consistency with regulatory definition of minimal self-adjustment
Deleted: A4466
Added: A4467
Deleted: K0901 & K0902 from the Reasonable Useful Lifetime table
Added: L1851 & L1852 to the Reasonable Useful Lifetime table
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: Modifiers
CODING GUIDELINES:
Removed: Reference to classification algorithm summary
Revised: OTS and custom-fit definitions to improve consistency with regulatory definition of "minimal self-adjustment"
Added: Section on coding of elastic and similar materials
Deleted: A4466
Deleted: K0901 & K0902
Added: A4467
Added: L1851
Added: L1852
Deleted: K0901 & K0902 from the Not Separately Payable table
Added: L1851 & L1852 to the Not Separately Payable table
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements Language Article
Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics)
LCD
Revision Effective Date: 01/01/2017
COVERAGE INDICATIONS, INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Removed: Standard Documentation Language
Added: New reference language and directions to Standard Documentation Requirements
Added: General Requirements
Revised: Refill Requirements
HCPCS Code:
Added: J8670
Deleted: Q9981
DOCUMENTATION REQUIREMENTS:
Removed: Standard Documentation Language
Added: General Documentation Requirements
Added: New reference language and directions to Standard Documentation Requirements
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Removed: Standard Documentation Language
Added: Direction to Standard Documentation Requirements
Removed: Information under Miscellaneous and Appendices
RELATED LOCAL COVERAGE DOCUMENTS:
Added: Standard Documentation Language article
Retired bulletin article titled: Coverage and Coding - New Oral Antiemetic Drug Varubi®- Revised- Effective Date July 1, 2016
Policy Article
Revision Effective Date: 01/01/2017
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Added: HCPCS J8670 for billing Rolapitant effective on or after 01/01/2017
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: Billing instructions and Modifiers section
CODING GUIDELINES:
Added: HCPCS J8670 for billing Rolapitant effective on or after 01/01/2017
RELATED LOCAL COVERAGE DOCUMENTS:
Added: The LCD-related Standard Documentation Requirements Language Article
Seat Lift Mechanisms
LCD
Revision Effective Date: 01/01/2017
COVERAGE INDICATIONS, INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Removed: Standard Documentation Language
Added: New reference language and directions to Standard Documentation Requirements
Added: General Requirements
HCPCS CODES:
Deleted: Code E0628
Revised: Code narratives for E0627 and E0629
DOCUMENTATION REQUIREMENTS:
Removed: Standard Documentation Language
Added: General Documentation Requirements
Added: New reference language and directions to Standard Documentation Requirements
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Removed: Standard Documentation Language
Added: Directions to Standard Documentation Requirements
Removed: Information under Miscellaneous and Appendices
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements article
Policy Article
Revision Effective Date: 01/01/2017
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: 42 CFR 410.38(g) and Certificate of Medical Necessity requirements
CODING GUIDELINES:
Removed: HCPCS Code E0628
Revised: HCPCS code narratives for Codes E0627 and E0629
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements Language Article
Spinal Orthoses: TLSO and LSO
LCD
Revision Effective Date: 01/01/2017
COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Removed: Standard Documentation Language
Added: New reference language and Directions to Standard Documentation Requirements
Added: General Requirements
HCPCS CODES:
Added: HCPCS Code A4467
Deleted: HCPCS Code A4466
DOCUMENTATION REQUIREMENTS:
Removed: Standard Documentation Language
Added: General Documentation Requirements
Added: New reference language and Directions to Standard Documentation Requirements
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Removed: Standard Documentation Language
Added: Directions to Standard Documentation Requirements
Removed: Supplier Manual reference from Miscellaneous section
Removed: Information under Appendices
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements article
Policy Article
Revision Effective Date: 01/01/2017
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised: Brace Benefit explanation to remove reference to "counterforce" that is no longer applicable
Revised: Prefabricated and OTS "minimal self-adjustment" regulatory definition discussion to improve consistency with regulatory definition of minimal self-adjustment
Deleted: A4466
Added: A4467
Added: Policy specific documentation requirements from LCD
CODING GUIDELINES:
Removed: Reference to classification algorithm summary
Revised: OTS and custom-fit definitions to improve consistency with regulatory definition of "minimal self-adjustment"
Added: Section on coding of elastic and similar materials
Deleted: A4466
Added: A4467
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements Language Article
Urological Supplies
LCD
Revision Effective Date: 01/01/2017
COVERAGE INDICATIONS, INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Removed: Standard Documentation Language
Added: New reference language and directions to Standard Documentation Requirements
Added: General Requirements
Revised: Refill Requirements
HCPCS Code:
Added: A4553
DOCUMENTATION REQUIREMENTS:
Removed: Standard Documentation Language
Added: General Documentation Requirements
Added: New reference language and directions to Standard Documentation Requirements
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Removed: Standard Documentation Language
Added: Direction to Standard Documentation Requirements
Removed: Information under Miscellaneous and Appendices
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements article
Policy Article
Revision Effective Date: 01/01/2017
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: Modifiers section
Added: A4553 to non-covered list
Wheelchair Options/Accessories
LCD
Revision Effective Date: 01/01/2017
COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Removed: Standard Documentation Language
Added: New reference language and Directions to Standard Documentation Requirements
Added: General Requirements
HCPCS CODES:
Revised: Descriptor changed in Group 1 - K0015, K0019; Group 2 - E0995, K0037, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0051, K0052; Group 4 -E0967, E2206, E2220, E2221, E2222, E2224, K0069, K0070, K0071, K0072, K0077; Group 8 - K0098
DOCUMENTATION REQUIREMENTS:
Removed: Standard Documentation Language
Added: General Documentation Requirements
Added: New reference language and Directions to Standard Documentation Requirements
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Removed: Standard Documentation Language
Added: Direction to Standard Documentation Requirements
Removed: Information under Miscellaneous
Removed: Information under Appendices
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements article
Policy Article
Revision Effective Date: 01/01/2017
NON MEDICAL NECESSITY PAYMENT RULES:
Added: Coverage rule for E0950
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: 42 CFR 410.38(g) and Modifier requirements
Added: Instructions for replacement codes
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements article
Note: The information contained in this article is only a summary of revisions to the LCDs and Policy Articles. For complete information on any topic, you must review the LCDs and/or Policy Articles.
