I would like to begin this editorial with some examples of statements that we've all heard that sound like policy or directives, especially when someone wants you to conform to a vague written or unwritten mandate: (1) "it's a Veterans Affairs regulation or policy," or (2) "it's a Centers for Medicare & Medicaid Services (CMS) or Durable Medical Equipment (DME) Medicare Administrative Contractors (MAC) policy." In these statements, however, clear verifiable evidence for the said policy or procedure is often lacking. The distinctions between policies and procedures are important, as they are often conflated. A policy is transparent, is usually in writing, can be readily verifiable in its purpose and scope, and may be corroborated by research or literature. On the other hand, a procedure can be unwritten or an established organizational behavior or a uniform way of doing a task, with uniform training (patient safety). Either way, these instruments rely on effective written or oral communication, and usually need further interpretation or clarity by the intended audience. A clearly articulated policy should contain evidence or a cogent reason. In a democratic society, professionals seek to understand the rationale for implementation of a given policy or procedure. In the case of patient coverage determinations by third-party administrators and subcontractors for CMS, who manage both delivery and expenditures of the patient care, the rationale for policies and procedures can be opaque, vague, and perceived to interfere with patient care. Recent determinations about advanced wound care dressings (Medicare Part B) are a case in point.
A recent policy1 produced by the National Heritage Insurance Company (NHIC Corp, Hingham, Massachusetts), which operates as a Medicare administrative contractor, DME MAC jurisdiction A in the United States, laid out in a 1-page "joint policy article (PA) from the DME MAC"1 their policy for "covered" and "noncovered" dressings. Their PA used arbitrary metrics, weights, or measures, by which to make coverage determinations, that is, based on the weight (seemingly determined by manufacturer information) and "predominant covered component of dressings."1 The PA states, "Historically, noncovered components have not been the majority constituent in multicomponent products." This PA identifies new codes for dressings, which may contain a noncovered predominant substance.
"The coding guideline for multicomponent dressings states that the clinically predominant component will determine classification. Following this guideline:
1. Dressings containing only noncovered components, with or without a substrate, are coded as A9270 (noncovered item or service)
2. Multicomponent dressings are coded based on the clinically predominant component for dressings that contain noncovered elements:
a. If the noncovered components are less than 50% of the dressing, coding is determined by the predominant covered component.
b. If the noncovered components comprise 50% or more of the dressing, the dressing is assigned to code A9270 (noncovered item or service)."1
To date, the only multicomponent dressings affected by the CMS, DME, and Pricing, Data Analysis and Coding (PDAC) by Noridian Healthcare Solutions (http://www.noridianmedicare.com/dme) policy are existing honey-impregnated and new silver-impregnated dressings.2
The aforementioned policy, however, was rescinded on June 12, 2015.1 A new PA was issued on June 11, 2015, which specifically identified medicinal honey-impregnated dressings1,2 "are to be coded based on the other components of the dressing." However, this "article" and others that address multicomponent dressings have been removed from the DME MAC websites without notice or further clarification. The arbitrary measure of 50% by weight against which honey-impregnated dressings have been judged has no basis in scientific or clinical literature. Based on the latest notice from the DME MACs, only "certain" honey-containing dressings and "all" honey-based gel/paste products were reassigned from Healthcare Common Procedure Coding System A9270, noncovered item, to A4649. Instead, these specific products are now to be coded by the miscellaneous surgical supplies code, A4649 (miscellaneous surgical supply code), and this requires submitting product-pricing information with the claims. In addition, the A4649 code with a descriptor of "Surgical Supply: Miscellaneous" does have coverage under Medicare Part B, but no associated fee schedule. The A4649 miscellaneous code requires a more involved process to submit claims. It is also more uncertain in terms of payment and claims accepted/rejected. Any change in the surgical dressing policy by CMS, DME MAC, and/or PDAC needs to be conducted in a transparent process and include consideration of validated measures/standardized testing methods not arbitrary metrics developed by the medical directors or consultants (contractors) of these entities.
References