CGS Administrators, LLC., and Noridian Healthcare Solutions, LLC., the A and B Medicare Administrative Contractors (MACs) for regions J-B, J-C, J-A and J-D revised the Local Coverage Determination (LCD): External Infusion Pumps (L33794) on 05/31/2020.
This LCD provides guidelines for justifying DMEPOS payment for supplies that are necessary for the effective use of durable medical equipment. This includes drugs and biologicals which must be put directly into the equipment for therapy or for the proper functioning of the equipment. However, the drug or biological itself must be reasonable and necessary for treatment of the illness or injury or to improve the functioning of a malformed body member.
Important Coverage and Billing Guidance Topics:
For the timely processing of claims, the LCD provides guidelines for:
- The indications for the coverage of an external infusion pump;
- Coverage of drugs when an infusion pump is covered
- Administration of other drugs
- An infusion controller device
- An IV pole (E0776)
- Supplies for the maintenance of a parenteral drug infusion catheter (A4221) or supplies for the maintenance for an insulin infusion pump (A4224)
- Supplies used with an external infusion pump, A4222 and K0552 or supplies used with an insulin infusion pump (A4225)
- Drugs and supplies that are dispensed that are dispensed for an emergency
- Charges for drugs administered by a DME infusion pump
- Compounded drugs NOC (J7999) billed with an external infusion pump
- Claims for compounded drugs that do not use code Q9977 or J7999
- Indications and settings of care that would result in denials of coverage for external infusion pumps, drugs and supplies
- General documentation requirements
- Policy specific documentation requirements
- Utilization Guidelines
The LCD also presents the guidance for billing and documentation requirements including the use of a Standard Written Order (SWO) and Written Order Prior to Delivery (WOPD) and DME Information Form (DIF).
Proof of delivery (POD) is required to be maintained and must be provided to the Medicare contractor upon request. Services that do not have appropriate POD from the supplier shall be denied as not reasonable and necessary.
Coverage and Billing Guidance for a New Product
This LCD also presents the evidence for a new Product – Xembify® and the professional society reviews of the evidence. Xembify® is a SCIG preparation approved for the treatment of PIDD. Based on the review of published clinical literature, evidence based clinical guidelines, and professional society recommendations, Xembify® was added to this LCD as it is considered safe and efficacious and improves the health outcomes of beneficiaries with a diagnosis of PIDD.
Therefore, the External Infusion Pump LCD (L33794) was updated to include coverage of Xembify® as reasonable and necessary for the treatment of beneficiaries with a diagnosis of PIDD.
Please refer to the LCD for coding, modifier use, coverage, billing and documentation requirements for your services and Products that are governed by this LCD. The LCD also has the refill requirements and Drug Wastage requirements that are important to note for your Products. If the drugs and services rendered are impacted by this policy, we can assist you with tracking the historical changes and appealing denials.
Why is it important to track policy changes using LCDs?
- The billing and documentation guidelines for your product are presented in the LCDs and the associated Articles and tracking their changes will help you assess billing, coding, or coverage impact on your Products.
- Providers rely heavily on payer policies for billing guidelines and coverage.
- Providers need to be educated on the documentation guidelines to reduce delays in payment.
- It helps to track competitor Products entering the market as competitor products and their coding and billing guidelines are mentioned in coverage policies
Why Partner with GIRS?
The GIRS Payer Advocacy Compass PAC® team has over 17 years of experience tracking payer policies and educating providers and stakeholders about changes to the policies to ensure coverage and reimbursement of our client’s medical technologies. Our work has enabled our clients to
- Analyze the impact of payer policy changes for our clients’ Products;
- comment on policy changes on time;
- correct mistakes in payer policies;
- clarify policy language for accounts;
- educate the sales force and accounts in new payer policy language;
- lay the foundation of customized payer advocacy strategies based on policy changes.
Please contact us at info@girsinc.com or avail of our Complimentary Review of your reimbursement needs at girsinc.com
Source: https://med.noridianmedicare.com/documents/2230703/7218263/External+Infusion+Pumps+LCD+and+PA
About GIRS
For more than 17 years, GIRS has been assisting medical technology manufacturers with their market uptake and reimbursement strategies so that patients can have access to the care that they need. To implement successful market access strategies, the GIRS Value Discovery Landscape Assessments® team and the Payer Advocacy Compass® team work together to develop and implement foundation reimbursement landscape and payer advocacy strategies to obtain positive coverage, appropriate payment, and innovative payer contracting arrangements to improve market uptake. For more information, email us at info@girsinc.com or call us at 901-834-9119.
Disclaimer: The information in this blog is based on payer information which is dynamic. It is accurate at the time of posting but should not be construed to be reimbursement or legal advice. CPT® is the trademark of the American Medical Association (AMA).