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BUSINESS: Coding Strategy

Evaluate the ‘Rule Book’

Local Coverage Determination documents help to create practice protocols

Last month, I asked you to print each Local Coverage Determination (LCD), or Medicare’s payment rule book, valid in your state and to apply that to procedures you perform. Any billing and coding compliance protocol you build in your practice should follow these guidelines.

This month, we will walk through an LCD (by subhead), specifically the LCD titled “Diagnostic evaluation and medical management of moderate-severe Dry Eye Disease (DED) (L36232),” which can be found at go.cms.gov/2SCC21n . Consider what you see in terms of creating a protocol for your practice.

LCD INFORMATION

On page 1, this subhead provides the effective date and retirement date to ensure the LCD is current.

BACKGROUND

This section tells you what to document in your chart for proper reimbursement. It holds a definition of dry eye, as well as concomitant conditions and commonly associated symptoms. These details should be used for better understanding of the disease and as the terminology you need to use for proper documentation in the medical record, when applicable.

DIAGNOSTIC TESTING

The section outlines relevant aspects of the dry eye work up and patient history. It says: “The initial evaluation of a patient who presents with a history or symptoms suggestive of DED should include…” Objective tests for DED commonly used for documenting and assessing the severity of DED are outlined. This is important because it supports frequency of visits and appropriate testing.

MANAGEMENT

In this section, you see mention that conservative treatments and interventions are expected to be attempted first, including elimination of exacerbating medications — when possible — and addressing environmental concerns, such as work site interventions. Appropriate medical therapy also is discussed. Pay special attention to the section on punctal plugs, which outlines materials and frequency, as it has been the subject of audits in recent months.

INDICATIONS

This section includes specific information on medical necessity for DED testing and treatment options that would need to be documented in the record.

LIMITATIONS

This section specifically states what is not covered by Medicare. It begins: “Testing of mild DED is not clinically useful because these patients cannot be differentiated from normal patients, and the resultant therapeutic intervention does not vary (e.g., tear supplementation, tear retention, tear stimulation, etc.).” This is a reminder that you must define the level of severity of DED to establish medical necessity for further testing to be covered by Medicare.

CODING INFORMATION

This section provides relevant codes for the services provided.

GENERAL INFORMATION

This section gives the provider documentation requirements for DED. In an audit, the requirements listed will be expected to be part of the record.

UTILIZATION GUIDELINES

This section delineates the expected frequency of testing for DED. One section, on page 10, specifically states: “Repetitive use of short-term or quick-dissolving (1-2 weeks) temporary lacrimal punctal plugs for treatment of dry eye disease would not be expected.”

YOU MADE IT THROUGH

As intimidating as it may be, I am sure you will find it refreshing, as I did, to have the rule book in your hands. OM