AOTA Advocates on Local Medicare Policy Affecting CA, HI, and NV
A troublesome local coverage determination (LCD) is causing concerns for occupational therapists. AOTA has learned that the LCD is being revised, and the Medicare contractor will automatically reprocess certain denied claims under the new LCD policy.
Palmetto GBA, the new Medicare Administrative Contractor (MAC) for Jurisdiction 1 (J1), is revising its new Part B LCD for Physical Medicine and Rehabilitation Policy. On September 2, 2008, the J1 MAC transitioned from National Heritage Insurance, Corp. (NHIC) to Palmetto GBA as a result of Medicare contracting reform mandated by the Medicare Modernization Act of 2003. J1 is composed of California, Hawaii, Nevada, American Samoa, Guam, and Northern Mariana Islands. Medicare required that Palmetto GBA adopt policies of previous J1 contractors and provide no opportunity for comment. The same physical medicine and rehabilitation policies apply to all states and territories in J1. The Physical Medicine and Rehabilitation LCD is online.
Palmetto GBA plans to post a revised LCD on October 16. AOTA is concerned that the LCD currently in place links coverage of CPT codes to ICD-9 codes and limits coverage. AOTA has been working with Palmetto GBA as it reviews the policies to provide input on appropriate therapy coverage. Palmetto GBA’s medical director has informed us that the upcoming revisions include:
• Uncoupling the ICD-9-CM and CPT codes
• Expanding the list of ICD-9-CM codes supporting medical necessity to include codes more reflective of therapy diagnoses in both the LCD and the Palmetto GBA claims system edits/audits
• Performing a mass adjustment using the expanded ICD-9-CM list
• Educating the J1 provider community about the revised LCD
If a claim was denied and includes an ICD-9 code that is on the new list of ICD-9 codes being developed by Palmetto GBA, the claim will be automatically reprocessed and the payment adjustment will be made. If a denied claim did not include an ICD-9 code on the new list, the provider must request a redetermination.
AOTA will post updates on our Web site when new information is available. If you are a provider located in J1 and have received recent claim denials because of uncovered ICD-9 codes, please share the relevant ICD-9 codes with our reimbursement department at email@example.com so that we may request that Palmetto GBA includes the codes in the revised LCD.