Local Coverage Determinations (LCDs) are decisions made by a Medicare Administrative Contractor (MAC) whether to cover a particular item or service in a MAC’s region. This blog post will dig into the new proposed Noridian Wound Care LCD language. We are suggesting that, even if you’re not under the Noridian jurisdiction, you should still know why it matters. Keep reading to find out.
Supplemental Medical Review Contractor (SMRC) and Noridian
The SMRC has been around for almost a decade and their primary role is to conduct nationwide medical reviews of Medicare providers and suppliers as directed by CMS. It is the responsibility of the SMRC to review medical records and related documentation to ensure that claims are processed in accordance with CMS guidelines.
In 2018, CMS awarded the SMRC contract to Noridian. One of the current projects under review by the SMRC is Outpatient Hyperbaric Oxygen Therapy (HBO). They are currently conducting a post-payment review of Medicare claims for HBO billed with service dates during the calendar year of 2018.
This is different from a Target Probe and Educate (TPE) because:
- TPE = pre payment reviews
- SMRC = post payment reviews
Even though the Targeted Probe and Educate (TPE) reviews have been suspended until further notice due to the COVID-19 Public Health Emergency (PHE), the SMRC medical review audits were allowed to resume on August 1, 2020.
As you can see, Noridian has been given quite a bit of responsibility, which we believe means Medicare is watching what they do in their jurisdiction and how it applies to the rest of the nation.
What this means moving forward
There is a strong interconnection that the reviews Nordian has conducted under the SMRC project likely led to the creation of this new proposed LCD. It seems plausible that Noridian, while reviewing the current Wound Care LCD’s for the other regions and MACs, began to see the different verbiage and different requirements outlined (or lack thereof).
There is some language from the other wound care LCD’s that appear to be verbatim and/or elaborated on in greater detail within this proposed LCD. Overall, I would not be surprised if the other MAC’s moved towards updating their wound care LCD’s – I would be more surprised if they didn’t.
Wound types eligible for debridement
Before we get into specific documentation requirements, the LCD outlines the following wound types as eligible for debridement:
- Surgical wounds that must be left open to heal by secondary intention
- Infected open wounds induced by trauma or surgery
- Wounds with biofilm
- Wounds associated with complicating autoimmune, metabolic, and vascular or pressure factors
- Open or closed wounds complicated by necrotic tissue and/or eschar
Documentation of Debridement Medical Necessity
Medicare wants to see documentation that the debridement will aid in:
- Minimizing infection risk
- The debridement is medically necessary to encourage healing granulation tissue to form
- The necrotic tissue impairs wound healing, and with the removal of this tissue will help promote wound healing
- Debridement would minimize conditions for bacterial overgrowth, other disease processes that could lead to pain, sepsis, and eventually amputation.
Special Emphasis Given to Biofilm
The Nordian LCD mentions the word biofilm many times. In the work that our CDI team conducts, a trend we see is a low level of documentation across the board regarding the presence of biofilm in chronic wounds. Here is an overview of what biofilm is and how it can support your documentation.
Biofilm is defined as a localized infection of skin and subcutaneous tissue. It is present on almost every chronic wound, however, there are no routine diagnostic tests to identify biofilm in wounds, which makes it particularly tricky to document.
It is thought that in chronic wound biofilm forms as a result of skin microenvironment disruption and infection by multiple microbe species. It must be removed to achieve wound healing.
- Debridement is one of the most important treatment strategies, but it does not remove all biofilm and cannot be used alone.
- Topical antiseptic application in combination with debridement may suppress regrowth of biofilm.
Biofilm is considered an infection and best classified as L08.89 in the world of ICD-10.
Again, the Nordian LCD mentions the word biofilm many times. If you are unfamiliar with Biofilm, take the time to research and discover more. Keep in mind it is important to include this as a part of overall debridement documentation as a supporting tool for documenting medical necessity for the debridement.
Another important documentation requirement that is outlined is the use of photographs. The wounds location, size, depth and stage must be documented and supported by a photograph. Good wound imaging practices are to:
- Photograph at the initiation of treatment
- Photograph before debridement
- Photograph after debridement
Photographic evidence can be used to support prolonged or repetitive debridement and can help to substantiate medical necessity for debridements. Oon a side, we recommend always including post debridement pictures even if your specific LCD does not require them.
If you don’t have the capability for wound imaging on your current EMR platform, Swift Medical has an imaging platform that can work with any EMR system.
Documentation of Goals
The goal for a non-healing wound is always full wound healing (with an exception for palliative care). There is an expectation that the treatment will:
- substantially affect tissue healing and viability,
- reduce or control tissue infection,
- remove necrotic tissue,
- or prepare the tissue for surgical management.
If wound closure is not a reasonable goal, then the expectation is to optimize recovery and establish an appropriate non-skilled maintenance program.
The Proposed LCD states that documentation must provide goals of the procedures performed. Full wound healing may seem like a very obvious reason as to why we are performing wound care on a patient, however, as stated, the LCD wants these goals documented and supported with evidence of medical necessity for the procedures that were performed.
First, read the LCD’s and then come back and re-read this blog post. You’ll then understand why we’ve chosen these specific areas to highlight.
Second, don’t let a third party management company decide these things for you. Take the time to educate yourself, your clinic, coding, and billing departments on proper documentation practices.
Third, if your LCD is less clear, then we suggest you begin following the Noridian LCD requirements.
Finally, feeling lost? I guarantee you’re not alone. If you need help deciphering documentation, please reach out.