November 2004 Medicare Bulletin - North Carolina Insert

Posted November 3, 2004

<< Back to the November 2004 Main Table of Contents

Local Coverage Determinations (LCDs) - Formerly Local Medical Review Policies (LMRPs)
North Carolina Health Professionals Shortage Areas (HPSAs)
North Carolina Mental Health Professional Shortage Areas (HPSAs)
North Carolina Policy Updates
Updated Surgical Add-On Code(s) Listing - North Carolina

Local Coverage Determinations (LCDs) – Formerly Local Medical Review Policies (LMRPs)

A “Local Coverage Determination” (LCD), as established by section 522 of the Benefits Improvement and Protection Act, is a decision by a fiscal intermediary or carrier whether to cover a particular service on an intermediary-wide or carrier-wide basis in accordance with Section 1862(a)(1)(A) of the Social Security Act (i.e., a determination as to whether the service is reasonable and necessary).

The final rule establishing LCDs was published 11/7/2003. Effective 12/07/2003, CMS’s contractors began issuing LCDs instead of LMRPs. Additionally, over the next 2 years contractors will convert all existing LMRPs into LCDs. Until the conversion is complete the term LCD will refer to both stand-alone LCDs and the “reasonable and necessary” provisions of an LMRP. For a listing of LCDs/LMRPs, you may access these on the Internet at: http://www.cignamedicare.com/medicare_dynamic/clickwrap/clickwrap.asp?url=ncpolicies

LCD Reconsideration Process
Contractors who have the task of developing LCDs shall have an LCD Reconsideration Process in accordance with the following instructions.

Purpose:
The LCD Reconsideration Process is a mechanism by which interested parties can request a revision to an LCD.

Background:
The LCD Reconsideration Process is available only for final LCDs. The whole LCD or any provision of the LCD may be reconsidered. Section 522 of The Benefits Improvement and Protection Act (BIPA), created the term “local coverage determination” (LCD). Until the conversion of all existing LMRPs into LCDs is complete, the term LCD refers to both:

Reasonable and necessary provisions of an LMRP; and
An LCD that contains only reasonable and necessary language.

Valid LCD Reconsideration Request Requirements

LCD reconsideration requests will be considered from:

Beneficiaries residing or receiving care in CIGNA’s jurisdiction;
Providers doing business in CIGNA’s jurisdiction;
Any interested party doing business in CIGNA’s jurisdiction.

CIGNA will only accept reconsideration requests for LCDs published in final form. Requests will not be accepted for other documents including:

National Coverage Decisions (NCD);
Coverage provisions in interpretive manuals;
Draft LCDs;
Template LCDs, unless or until they are adopted by CIGNA;
Retired LCDs;
Individual claim determinations;
Bulletins, articles, training materials; and
Any instance in which no LCD exists, i.e., requests for development of an LCD.
If modification of the LCD would conflict with an NCD, the request would not be valid. For these requests, CIGNA suggests that the requestor review the NCD reconsideration process according to the CMS Manual System, Pub 100-8, Medicare Program Integrity, Chapter 13, Section 13.1.1, (http://www.cms.hhs.gov/manuals/).

Requests shall be submitted in writing, and must identify the language that the requestor wants added to or deleted from an LCD. Requests must include a justification supported by new evidence, which may materially affect the LCD’s content or basis. Copies of published evidence must be included.

The level of evidence required for LCD reconsideration is the same as that required for new LCD development. (PIM Chapter 13, Section 13.7.1)

There are several ways you can send CIGNA your LCD Reconsideration requests:

By U.S. Postal Service:

Boyd K. Honeycutt, M.D., MBA, FACP
Carrier Medical Director
CIGNA Government Services
4135 Mendenhall Oaks Parkway, Suite 101
High Point, NC 27265

By e-mail: boyd.honeycutt@cigna.com

By fax: 336.821.4591

Within 30 days of the day the request is received, CIGNA will determine if the request is valid or invalid. Any request for LCD reconsideration that, in the judgment of CIGNA, does not meet the criteria described above, is invalid.
If the request is valid:

Within 90 days of the day the request was received, CIGNA will make a final LCD reconsideration decision on the valid request and notify the requestor of the decision with CIGNA’s rationale. Decision options include retiring the policy, no revision, revision to a more restrictive policy, or revision to a less restrictive policy.
If the decision is to revise the LCD, CIGNA will follow the normal process for LCD development.
CIGNA will consolidate valid requests, if similar requests are received.

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Policy Updates

Extracorporeal Shock Wave Therapy for Musculoskeletal Problems (LMRP 2003-001-01)

The language in this policy was changed to inform providers that documentation must be maintained in the medical record, but not submitted with any claims.

B12 Injection (LMRP 95-02)

The following codes have been added to those that may support medical necessity:

162.0	Malignant Neoplasm of Trachea
162.2	Malignant Neoplasm of Main Bronchus
162.3	Malignant Neoplasm of Upper Lobe Bronchus or Lung
162.4	Malignant Neoplasm of Middle Lobe Bronchus or Lung
162.5	Malignant Neoplasm of Lower Lobe Bronchus or Lung
162.8	Malignant Neoplasm of Other Parts of Bronchus or Lung
162.9	Malignant Neoplasm of Bronchus and Lung Unspecified

The following policy has been retired with an effective date of 10/01/2004:

Corneal Transplant Wound Revisions (LMRP 92-01)

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Updated Surgical Add-On Code(s) Listing

Certain surgical procedure codes are add-on codes that are always billed with another service. These add-on codes have a ZZZ indicated in the post-operative period. Post-operative work is not included in the fee schedule payment for the ZZZ codes.

Listed below are the surgical add-on codes and their primary procedure codes. Payment will not be made for these add-on codes unless billed in addition to accompanying primary procedure.

CHART FOR ZZZ (ADD-ON) CODES

ZZZ ADD-ON CODE	PRIMARY CODE
01968 – 01969	01967
11001	11000
11101	11100
11201	11200
11732	11730
11922	11920, 11921
13102	13101
13122	13121
13133	13132
13153	13152
15001	15000
15101	15100
15121	15120
15201	15200
15221	15220
15241	15240
15261	15260
15343	15342
15351	15350
15401	15400
15787	15786
16036	16035
17003	17000
17310	17304-17307
19001	19000
19126	19125
19291	19290
19295	19102, 19103
19340	19140-19162, 19180-19240, 19316-19318, 19357, 19364-19369, 19380
22103	22100-22102
22116	22110-22112, 22114
22216	22210-22214
22226	22220-22224
22328	22325-22327
22522	22520-22521
22534	22532, 22533
22585	22554-22558
22614	22600-22612
22632	22630
22840	22325-22327, 22548-22812
22842	22325-22327, 22548-22812
22843	22325-22327, 22548-22812
22844	22325-22327, 22548-22812
22845	22325-22327, 22548-22812
22846	22325-22327, 22548-22812
22847	22325-22327, 22548-22812
22848	22325-22327, 22548-22812
22851	22325-22327, 22548-22812
26125	26121, 26123
26861	26860
26863	26862
27358	27355-27357
27692	27690-27691
31632	31628
31633	31629
32501	32480-32484
33141	33510-33536, 33572
33225	33206-33208, 33212-33214, 33216-33217, 33222, 33233-33235, 33240, 33249
33508	33510-33523
33517	33533-33536
33518	33533-33536
33519	33533-33536
33521	33533-33536
33522	33533-33536
33523	33533-33536
33530	33400-33496, 33510-33536, 33863
33572	33510-33516, 33533-33536
33924	33470-33475, 33600-33619, 33684-33688, 33692-33697, 33735-33767, 33770-33786
34808	34800, 34813, 34825, 34826
34813	34812
34826	34825
35390	35301
35400	35201-35381,35585, 35566,35556
35500	33510-33536, 35556, 35566
35572	33510-33523, 34502, 34520, 35001-35002, 35011-35022, 35102-35103, 35121-35152, 35231-35256, 35501-35587, 35879-35907
35600	33533-33536
35682	35501-35587
35683	35501-35587
35697	34800-34805, 34825, 34830, 34832, 35081-35103
35700	35556, 35566, 35571, 35583-35587, 35656, 35666-35671
36218	36216-36217
36248	36246-36247
37206	37205
37208	37207
Added/Updated 37250	Added/Updated 36215-36248, 37200-37208, 61624, 61626, 34800-34826
Added/Updated 37251	Added/Updated 37250, 34800-34826
43635	43631-43634
44121	44120
44701	44140, 44145, 44150, 44604
47550	47600-47620
48400	43260-43272
49568	49560-49566
56606	56605
58611	43020-43634, 43638-44010, 44020-44120, 44125-44130, 44140-44950, 44960-47000, 47010-48180, 49500-49566, 49570-49900, 59510-59525
59525	59510-59515, 59618-59622
60512	60500, 60502, 60505, 60212, 60225, 60240, 60252, 60254, 60260, 60270, 60271
61316	61304, 61312-61313, 61322-61323, 61340, 61570-61571, 61680-61705
61517	61510, 61518
61609	61607-61608
61610	61607-61608
61611	61605-61606
61612	61605-61606
61795	61304-61692, 61700-61711, 63001-63091, 22100-22328, 22548-22851, 31254-31256, 31267, 31276, 31287-31288, 31290-31294
61864	61863
61868	61867
62148	62140-62147
62160	61107, 61210, 62220, 62223, 62225, 62230
63035	63020-63030
63043	63040
63044	63042
63048	63045-63047
63057	63055-63056
63066	63064
63076	63075
63078	63077
63082	63081
63086	63085
63088	63087
63091	63090
63103	63101, 63102
63308	63300-63307
64443	64442
64472	64470
64476	64475
64480	64479
64484	64483
64623	64622
64727	64702-64726
64778	64776
64783	64782
64787	64774-64786
64832	64831
64837	64834-64836
64859	64856-64858
64872	64831-64870, 64874-64907
64874	64831-64872, 64876
64876	64831-64874
64901	64885-64893
64902	64885, 64886, 64895-64898
66990	65820, 65875, 65920, 66985-66986, 67038-67048
69990	61304-61711, 62010-62100, 63081-63308, 63704-63710, 64831, 64834-64836, 64840-64858, 64861-64870, 64885-64898, 64905-64907
67225	67221
67320	67311-67318
67331	67311-67318
67332	67311-67318
67334	67311-67318
67335	67311-67334
67340	67311-67320, 67331-67334
74301	74300
75774	75600-75790, 36215-36248
75946	75945
75964	75962
75968	75966
75993	75992
75998	36555-36585
75996	75995
76085	76092, G0202
76802	76801
76810	76805
76812	76811
Added/Updated 76937	Added/Updated 36555-36585, 36481,36000, 36012, 36245, 36005, 36620, 36011, 36500
78020	78018
78478	78460-78465
78480	78460-78465
78496	78472
88155	88142-88145, 88150-88154, 88164-88167
90781	90780
92547	92541-92546
92979	92978
92981	92980, G0290
92984	92980, 92982, 92995,G0290
92996	92980, 92982, 92995
92998	92997
93320	93303-93317, 93350
93321	93303-93317, 93350
93325	76825-76828, 93303-93321, 93350
93571	92980-92984, 92995-92996, 93508, 93539-93540, 93545, G0290
93572	93571
93623	93620-93622
93662	93621-93622, 93651-93652, 93580-93581
95920	92585, 95925-95937
95962	95961
95973	95972
95975	95974
96412	96410
96423	96422
96570	31641, 43228
96571	31641, 43228
97546	97545
99292	99291
99354	99201-99205, 99212-99215, 99241-99245, 99341-99345, 99347-99350
99355	99354
99356	99221-99223, 99231-99233, 99251-99255, 99261-99263, 99301-99303, 99311-99313
99357	99356
76082	76090, 76091, G0204, G0206
G0275	93508, 93510-93511, 93524, 93526-93529, 93531-93533, 93539-93541, 93543-93545
G0278	93508, 93510-93511, 93524, 93526-93529, 93531-93533, 93539-93541, 93543-93545
G0289	29873, 29875, 29880-29889
G0291	92980, G0290

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North Carolina Mental Health Professional Shortage Areas (HPSAs)

Designated Geographic Areas

COUNTY	AREA NAME/PARTS	RURAL/URBAN
Beaufort	Tideland Beaufort	Rural
Bertie	Roanoke-Chowan Bertie	Rural
Bladen	Southeast Regional Blanden	Rural
Brunswick	Brunswick	Rural
Caldwell	Caldwell	Urban
Camden	Albermarle Camden	Rural
Cherokee	Smokey Mountain Cherokee	Rural
Chowan	Albermarle Chowan	Rural
Clay	Smokey Mountain Clay	Rural
Columbus	Southeast Regional Columbus	Rural
Currituck	Albermarle Currituck	Rural
Dare	Albermarle Dare	Rural
Duplin	Duplin-Sampson Duplin	Rural
Gates	Roanoke-Chowan Gates	Rural
Graham	Smokye Mountain Graham	Rural
Halifax	Halifax MHCA Halifax	Rural
Haywood	Smokey Mountain Haywood	Rural
Hertford	Roanoke-Chowan Hertford	Rural
Hyde	Tideland Hyde	Rural
Jackson	Smokey Mountain Jackson	Rural
Macon	Smokey Mountain Macon	Rural
Martin	Tideland Martin	Rural
Northampton	Roanoke-Chowan Nothampton	Rural
Pasquotank	Albermarie Pasquotank	Rural
Perquimans	Albermarle Perquimans	Rural
Robeson	Southeast Regional Robeson	Rural
Sampson	Duplin-Sampson Sampson	Rural
Scotland	Southeast Regional Scotland	Rural
Surry	Surry-Yadkin Surry	Rural
Swain	Smokey Mountain Swain	Rural
Tyrrell	Tideland Tyrell	Rural
Washington	Tideland Washington	Rural
Yadkin	Surry-Yadkin Yadkin	Rural

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North Carolina Health Professional Shortage Areas (HPSAs)

Designated Geographic Areas

COUNTY	AREA NAME/PARTS	RURAL/URBAN
Alexander	All	Urban
Anson	All	Rural
Beaufort	Bayboro - Aurora Richland Twp. Belhaven - Swan Quarter Bath Twp., Pantego Twp	Rural
Bertie	All	Rural
Bladen¹	All	Rural
Caldwell	Western Caldwell - Globe Twp., Johns River Twp., Mulberry Twp., Patterson Twp., Wilson Creek Twp.,	Rural
Carteret¹	Eastern Cateret - Atlantic Twp., Cedar Island Twp., Davis Twp., Harkers Islands Twp., Marshallberg Twp., Merrimon Twp., Portsmouth Twp., Sea Level Twp., Smyrna Twp., Stacy Twp., Strait Twp.	Rural
Caswell	All	Rural
Cherokee³	Andrews Area, Valley Town Twp.	Rural
Clay	All	Rural
Columbus	All	Rural
Currituck	All	Urban
Dare	Hatteras - Ocracoke SA Hatteras Twp., Kinnakeet Twp.	Rural
Edgecombe	All	Urban
Franklin	All	Urban
Gates	All	Rural
Graham	All	Rural
Greene²	All	Rural
Guilford	Inner City Greensboro - Census Tracts 101, 107.02, 108.01, 110, 111.01, 112, 113, 114, 115	Urban

Hoke	All	Rural
Hyde	Belhaven-Swan Quarter Currituck Twp., Fairfield Twp., Lake Landing Twp., Lake Mattamuskeet Unorg., Swan Quarter Twp. Hatteras-Ocracoke Ocracoke Twp.	Rural
Lenoir	East Kinston - Census Tracts 101-105, 107	Urban
Macon¹	Franklin - Burningtown Twp., Cartoogechaye Twp., Cowee Twp., Ellijay Twp., Flats Twp., Franklin Twp., Millshoal Twp., Nantahala Twp., Smiths Bridge Twp.	Rural
Mecklenburg	Central Charlotte - Census Tracts 1, 4, 5, 6, 7, 8, 36, 37, 38.98, 39.01, 39.02, 41, 42, 45, 46, 47, 48, 49, 50, 51, 51.01, 52	Urban
Montgomery¹	All	Rural
Northampton	All	Rural

Pamlico	Bayboro - Aurora	Rural
Pender	All	Rural
Person	All	Rural
Randolph	All	Urban
Robeson	All	Rural
Stokes	Danbury - Census Tracts 701, 702, and 703	Urban
Tyrrell	All	Rural
Warren	All	Rural
Washington	All	Rural

¹ No longer classified as a HPSA, effective August 1, 2002.
² Classifed as a HPSA, effective June 1, 2004.

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