Podiatry: Coverage and Medical Review of Hyperkeratotic Lesion Treatment - Questions and Answers

The following questions were received during our August 7, 2018 webcast.

Q. Where can we find the finding (results) and close dates for an identified non-TPE prepayment audit such as CPT code 99285?

A. On our website, www.PalmettoGBA.com/RR, if you go to our Topics section, choose Medical Review and then choose Notification Articles. These articles tell what reviews are planned for the year. If you are looking for review results, those are found in the Review Results section.

If you are looking for TPE review codes, each provider will get their own results. Once you’re on TPE, you will go through the process of round one. If you have a low error rate, then you will come off of review for that code for a year. If you have a higher error rate, you will progress to the second round of TPE. You can progress through three rounds of TPE. Hopefully by the third round, and with one-on-one education, the provider will be able to supply the documentation pieces that are being reviewed.

In order to complete the TPE process, when you first receive a TPE notification letter it is very important that you complete it and provide a point of contact who will be able to talk about what your documentation contains, and what the reviewers are looking for so they will be able to help you through the TPE process.

Addendum: The findings of prepayment reviews, other than TPE reviews, are communicated through quarterly review results articles. These articles also include the future plans for the review. If the review will be ongoing, the future plans will state the results from the next widespread review will be published at the conclusion of the next quarter.

Q: Within the review results for a specified audit, it does not state the close date. It does state "Review of Anesthesia Service claims submitted from January 2018 through March 2018." Is this indicative of a closure (ex CPT code 00607)? When looking at the Active Medical Reviews are we to assume that the CPT/HCPCS listed are the only open audits and all others have been closed?

A: Planned reviews generally are published at the start of the fiscal year. Data analysis and review results are considered when determining if a HCPCS/CPT code should continue to be reviewed. Medicare’s expectation is that regardless of review status, all providers are expected to be in compliance at all times.

The latest article on anesthesia service, "Widespread Review Anesthesia for Extensive Spine and Spinal Cord Procedures: Third Quarter of FY 2018" states in the "Future Plans" paragraph:  "At the present time, the review of this service will be suspended so no results will be posted for next quarter." If a Widespread Review article does not contain a statement about completion of the review, then the review will continue into the next quarter.

Q. Just want to confirm, you stated the date they are going to be seen by their PCP can be used as well? Or just date last seen?

A. The claim or other available evidence must indicate that the patient has been seen by the provider, who follows them for the treatment and/or evaluation of a complicating disease process, in the last six months before the routine-type services were rendered, or within 30 days after the foot care service was rendered.

Addendum: An appointment date with the provider who is following the patient for the treatment and/or evaluation of the a complicating disease process should occur in the six months prior to the routine-type podiatry services being rendered.

Per the CMS guidelines in IOM Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 290 – Foot Care, the patient should have a visit with a referring provider in the 60 days before foot care if being treated due to a systemic condition.

An appointment date that occurs within 30 days after the routine-type podiatry services are rendered is not generally accepted. However, as a national Medicare Administrative Contactor, Railroad Medicare will accept a visit date that occurs shortly after the podiatry service is rendered in the case of  a provider whose local Medicare Administrative Contactor has a Local Coverage Determination (LCD) that allows a future visit date.

Q. On the CMS website, on the foot care policy, they have taken out the 30 days previous MD/DO appointment, so you have not made this change?

A. At present, we are accepting appointment dates that are within 30 days after a foot care service. We want to encourage you to stay updated by using our website to view our podiatry information to see if coverage continues for that, or if any changes have taken place. 

Addendum: An appointment date with the provider who is following the patient for the treatment and/or evaluation of the a complicating disease process should occur in the six months prior to the routine-type podiatry services being rendered.

Per the CMS guidelines in IOM Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 290 – Foot Care, the patient should have a visit with a referring provider in the 60 days before foot care if being treated due to a systemic condition.

An appointment date that occurs within 30 days after the routine-type podiatry services are rendered is not generally accepted. However, as a national Medicare Administrative Contactor, Railroad Medicare will accept a visit date that occurs shortly after the podiatry service is rendered in the case of  a provider whose local Medicare Administrative Contactor has a Local Coverage Determination (LCD) that allows a future visit date.      

Q: Where do I find the claim submission cover sheet for CPT codes 1055-11056?

A: This is available on our Medical Review checklist page. From our homepage, www.PalmettoGBA.com/RR, look for the Top Links section, which is a green and white box on the left-hand side. There you will find a link for Medical Review. That link will open our Medical Review page where you will find a link to Checklists. On the Checklist page you will find multiple checklists that are titled by the procedure code or the service. You should be able to find the claim submission coversheet for those on our Checklist page.

Q: Can you use the systemic condition as a primary diagnosis for routine foot care?

A: Yes, a systemic condition can be a primary diagnosis for routine foot care services. A systemic condition is equivalent to a patient’s medical diagnosis.

Q: Where can we find more info about class findings?

A. You can find more information about class findings in the CMS IOM, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 290-Foot Care. Also in the MLN Medicare Podiatry Services: Information for Medicare Fee-for-Service Health Care Professionals Fact Sheet. Links to both of these resources are found in our Resource List. 

Q: What is the course number of this presentation?

A. The course number for today is RRB1794598. This can be added to you certificate of attendance for today that is available in our resource list of this presentation.

Contact Railroad Medicare

Email Railroad Medicare

Contact a specific Railroad Medicare department

Provider Contact Center: 888-355-9165

IVR: 877-288-7600

TTY: 877-715-6397

Other Palmetto GBA Sites

Palmetto GBA Home

DMEPOS Competitive Bidding Program

Jurisdiction J Part A MAC

Jurisdiction J Part B MAC

Jurisdiction M Part A MAC

Jurisdiction M Part B MAC

Jurisdiction M Home Health and Hospice MAC

MolDX

National Supplier Clearinghouse MAC

PDAC

RRB Specialty MAC Providers

RRB Specialty MAC Beneficiaries

Anonymous

 

Click to Chat Now